Durable Power Of Attorney For Health Care - State Of Georgia (Page 2 of 7) in pdf

In section 8, sign and print your name, address, phone numbers, and the date before two

(d)

witnesses. If you are not physically able to do these things, Georgia law allows another person to sign and

date the form on your behalf, as long as he or she does so at your direction, in your presence and in the

presence of the two witnesses.

The two witnesses must be competent adults (18 years or older). Neither of them should be the person

you have appointed as your agent or successor agent. They may, however, be your relatives.

In the DECLARATION OF WITNESSES section beneath your signature, the date should be

(e)

inserted and the two witnesses should sign their names and insert their addresses beneath their

signature.

IF YOU ARE A PATIENT IN A HOSPITAL OR SKILLED NURSING FACILITY, the

(f)

Durable Power of Attorney for Health Care must also be witnessed by your attending physician, who

should date and sign the ATTENDING PHYSICIAN ATTESTATION below the Declaration of

Witnesses section.

It is recommended that you keep the original of this form among your valuable papers; and that

(g)

you distribute copies to the agent (and successor agent) you have designated in section 1, to the rabbi and

institution/organization you have designated in section 3, as well as to your doctors, your lawyer, and

anyone else who is likely to be contacted in times of emergency.

We also recommend that you register a copy

of this form with a national living will registry, so that it can be accessed by any health care facility via computer.

Agudath Israel has made an arrangement with the New York Legal Assistance Group to register Halachic Living

Wills for our constituents with the U.S. Living Will Registry at no charge. Contact our office (212-797-9000 ext.

267) for the forms that will enable you to do this.

If at any time you wish to revoke this Durable Power of Attorney for Health Care, you may

(h)

do so by destroying it, by a written revocation which is signed and dated by you or by someone else at

your direction, by an oral or other expression of your intent to revoke it before a competent witness who

confirms such expression in a dated and signed writing within 30 days of your expression, or by

executing a new copy of this form. By law, your marriage after the execution of this Durable Power of

Attorney for Health Care automatically revokes any designation of an agent other than a designation of your

spouse. Also, an appointment of your spouse as your agent is automatically revoked upon divorce or

dissolution of your marriage.

If you do not revoke the Durable Power of Attorney for Health Care, Georgia law provides that it

remains in effect indefinitely. Obviously, if any of the persons you have appointed in the Durable Power of

Attorney for Health Care dies or becomes otherwise incapable of serving in the role you have assigned, it

would be wise to execute a new Durable Power of Attorney for Health Care.

It is recommended that you also complete the Emergency Instructions Card contained in the

(i)

Halachic Living Will brochure and carry it with you in your wallet or purse.

If, upon consultation with your rabbi, you would like to add to this standardized Durable Power of

(j)

Attorney for Health Care any additional expression of your wishes with respect to medical and/or post-mortem

decisions, you may do so by attaching a “rider” to the standardized form. If you choose to do so, or if you

have any other questions concerning this form, please consult an attorney.

These instructions are not part of the Halachic Living Will and need not be kept attached to the executed

document.

Durable Power Of Attorney For Health Care - State Of Georgia Page 2

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