Georgia Advance Directive For Health Care printable pdf download

Georgia Advance Directive for Health Care

By:

Date of Birth:

(Print Name)

(Month/Day/Year)

This advance directive for health care has four parts:

PART ONE—Health Care Agent. This part allows you to choose someone to make health care decisions for you when you

cannot (or do not want to) make health care decisions for yourself. The person you choose is called a health care agent. You

may also have your health care agent make decisions for you after your death with respect to an autopsy, organ donation,

body donation, and final disposition of your body. You should talk to your health care agent about this important role.

PART TWO—Treatment Preferences. This part allows you to state your treatment preferences if you have a terminal

condition or if you are in a state of permanent unconsciousness. PART TWO will become effective only if you are unable to

communicate your treatment preferences. Reasonable and appropriate efforts will be made to communicate with you about

your treatment preferences before PART TWO becomes effective. You should talk to your family and others close to you

about your treatment preferences.

PART THREE—Guardianship. This part allows you to nominate a person to be your guardian should one ever be needed.

PART FOUR—Effectiveness and Signatures. This part requires your signature and the signatures of two witnesses. You

must complete PART FOUR if you have filled out any other part of this form.

You may fill out any or all of the first three parts listed above. You must fill out PART FOUR of this form in order for this form to

be effective.

You should give a copy of this completed form to people who might need it, such as your health care agent, your family, and

your physician. Keep a copy of this completed form at home in a place where it can easily be found if it is needed. Review this

completed form periodically to make sure it still reflects your preferences. If your preferences change, complete a new

advance directive for health care.

Using this form of advance directive for health care is completely optional. Other forms of advance directives for health care

may be used in Georgia.

You may revoke this completed form at any time. This completed form will replace any advance directive for health care,

durable power of attorney for health care, health care proxy, or living will that you have completed before completing this form.

PART ONE—Health Care Agent

PART ONE will be effective even if PART TWO is not completed. A physician or health care provider who is directly involved

in your health care may not serve as your health care agent. If you are married, a future divorce or annulment of your marriage

will revoke the selection of your current spouse as your health care agent. If you are not married, a future marriage will revoke

the selection of your health care agent unless the person you selected as your health care agent is your new spouse.

1. Health Care Agent

I select the following person as my health care agent to make health care decisions for me:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

Georgia Advance Directive For Health Care