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Free Georgia Healthcare Power of Attorney Form

Download Healthcare Power of Attorney for the State of Georgia.

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Georgia Healthcare Power of Attorney Form

Text Version of the Form

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GEORGIA STATUTORY SHORT FORM
DURABLE POWER OF ATTORNEY FOR HEALTH CARE

NOTICE: THE PURPOSE OF THIS POW ER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR
AGENT) BROAD POW ERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING POW ER TO REQUIRE,
CONSENT TO, OR W ITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL TREATMENT FOR ANY PHYSICAL
OR MENTAL CONDITION AND TO ADMIT YOU TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME, OR OTHER
INSTITUTION; BUT NOT INCLUDING PSYCHOSURGERY, STERILIZATION, OR INVOLUNTARY HOSPITALIZATION
OR TREATMENT COVERED BY TITLE 37 OF THE OFFICIAL CODE OF GEORGIA ANNOTATED. THIS FORM DOES
NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POW ERS; BUT, W HEN A POWER IS
EXERCISED, YOUR AGENT W ILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE
WITH THIS FORM. A COURT CAN TAKE AWAY THE POW ERS OF YOUR AGENT IF IT FINDS THE AGENT IS NOT
ACTING PROPERLY. YOU MAY NAME COAGENTS AND SUCCESSOR AGENTS UNDER THIS FORM, BUT YOU
MAY NOT NAME A HEALTH CARE PROVIDER WHO MAY BE DIRECTLY OR INDIRECTLY INVOLVED IN
RENDERING HEALTH CARE TO YOU UNDER THIS POW ER. UNLESS YOU EXPRESSLY LIMIT THE DURATION OF
THIS POW ER IN THE MANNER PROVIDED BELOW OR UNTIL YOU REVOKE THIS POW ER OR A COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY EXERCISE THE POW ERS GIVEN IN THIS POW ER
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.
THE POW ERS YOU GIVE YOUR AGENT, YOUR RIGHT TO REVOKE THOSE POW ERS, AND THE PENALTIES FOR
VIOLATING THE LAW ARE EXPLAINED MORE FULLY IN CODE SECTIONS 31-36-6, 31-36-9, AND 31-36-10 OF THE
GEORGIA “DURABLE POW ER OF ATTORNEY FOR HEALTH CARE ACT” OF WHICH THIS FORM IS A PART (SEE
THE BACK OF THIS FORM). THAT ACT EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF POW ER
OF ATTORNEY YOU MAY DESIRE. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

DURABLE POW ER OF ATTORNEY made this _____ day of ______________ , ____ .

1. I, _________________________________________________________________
(insert name and address of principal)
hereby appoint ___________________________________________
insert name and address of agent)
as my attorney in fact (my agent) to act for me and in my name in any way I could act in person to
make any and all decisions for me concerning my personal care, medical treatment,
hospitalization, and health care and to require, withhold, or withdraw any type of medical
treatment or procedure, even though my death may ensue. My agent shall have the same access
to my medical records that I have, including the right to disclose the contents to others. My agent
shall also have full power to make a disposition of any part or all of my body for medical
purposes, authorize an autopsy of my body, and direct the disposition of my remains.

THE ABOVE GRANT OF POW ER IS INTENDED TO BE AS BROAD AS POSSIBLE SO THAT YOUR AGENT W ILL
HAVE AUTHORITY TO MAKE ANY DECISION YOU COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF
HEALTH CARE, INCLUDING W ITHDRAWAL OF NOURISHMENT AND FLUIDS AND OTHER LIFE-SUSTAINING OR
DEATH-DELAYING MEASURES, IF YOUR AGENT BELIEVES SUCH ACTION WOULD BE CONSISTENT W ITH YOUR
INTENT AND DESIRES. IF YOU WISH TO LIMIT THE SCOPE OF YOUR AGENT´S POW ERS OR PRESCRIBE
SPECIAL RULES TO LIMIT THE POW ER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE AUTOPSY, OR DISPOSE
OF REMAINS, YOU MAY DO SO IN THE FOLLOW ING PARAGRAPHS.

2. The powers granted above shall not include the following powers or shall be subject to the
following rules or limitations (here you may include any specific limitations you deem appropriate,
such as your own definition of when life-sustaining or death-delaying measures should be
withheld; a direction to continue nourishment and fluids or other life-sustaining or death-delaying
treatment in all events; or instructions to refuse any specific types of treatment that are
inconsistent with your religious beliefs or unacceptable to you for any other reason, such as blood
transfusion, electroconvulsive therapy, or amputation):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

THE SUBJECT OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT IS OF PARTICULAR IMPORTANCE. FOR
YOUR CONVENIENCE IN DEALING W ITH THAT SUBJECT, SOME GENERAL STATEMENTS CONCERNING THE
WITHHOLDING OR REMOVAL OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT ARE SET FORTH
BELOW . IF YOU AGREE W ITH ONE OF THESE STATEMENTS, YOU MAY INITIAL THAT STATEMENT, BUT DO NOT
INITIAL MORE THAN ONE:

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I do not want my life to be prolonged nor do I want life-sustaining or death-delaying treatment to
be provided or continued if my agent believes the burdens of the treatment outweigh the
expected benefits. I want my agent to consider the relief of suffering, the expense involved, and
the quality as well as the possible extension of my life in making decisions concerning life-
sustaining or death-delaying treatment.

Initialed ______

I want my life to be prolonged and I want life-sustaining or death-delaying treatment to be
provided or continued unless I am in a coma, including a persistent vegetative state, which my
attending physician believes to be irreversible, in accordance with reasonable medical standards
at the time of reference. If and when I have suffered such an irreversible coma, I want life-
sustaining or death-delaying treatment to be withheld or discontinued.

Initialed ______

I want my life to be prolonged to the greatest extent possible without regard to my condition, the
chances I have for recovery, or the cost of the procedures.

Initialed ______

THIS POW ER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU AT ANY TIME AND IN ANY MANNER
WHILE YOU ARE ABLE TO DO SO. IN THE ABSENCE OF AN AMENDMENT OR REVOCATION, THE AUTHORITY
GRANTED IN THIS POW ER OF ATTORNEY W ILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED
AND W ILL CONTINUE UNTIL YOUR DEATH AND W ILL CONTINUE BEYOND YOUR DEATH IF ANATOMICAL GIFT,
AUTOPSY, OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE
OR DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF THE FOLLOW ING:

3. ( ) This power of attorney shall become effective on ________________________ (insert a
future date or event during your lifetime, such as court determination of your disability, incapacity,
or incompetency, when you want this power to first take effect).

4. ( ) This power of attorney shall terminate on _______________________ (insert a future date
or event, such as court determination of your disability, incapacity, or incompetency, when you
want this power to terminate prior to your death).

IF YOU W ISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND ADDRESSES OF SUCH SUCCESSORS
IN THE FOLLOW ING PARAGRAPH:

5. If any agent named by me shall die, become legally disabled, incapacitated, or incompetent, or
resign, refuse to act, or be unavailable, I name the following (each to act successively in the order
named) as successors to such agent :

___________________________________________________________________
___________________________________________________________________

IF YOU W ISH TO NAME A GUARDIAN OF YOUR PERSON IN THE EVENT A COURT DECIDES THAT ONE SHOULD
BE APPOINTED, YOU MAY, BUT ARE NOT REQUIRED TO, DO SO BY INSERTING THE NAME OF SUCH GUARDIAN
IN THE FOLLOW ING PARAGRAPH. THE COURT W ILL APPOINT THE PERSON NOMINATED BY YOU IF THE
COURT FINDS THAT SUCH APPOINTMENT W ILL SERVE YOUR BEST INTERESTS AND W ELFARE. YOU MAY, BUT
ARE NOT REQUIRED TO, NOMINATE AS YOUR GUARDIAN THE SAME PERSON NAMED IN THIS FORM AS YOUR
AGENT.

6. If a guardian of my person is to be appointed, I nominate the following to serve as such
guardian: __________________________________________________________________
(insert name and address of nominated guardian of the person)

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7. I am fully informed as to all the contents of this form and understand the full import of this grant
of powers to my agent.

Signed _________________________________
(Principal)

The principal has had an opportunity to read the above form and has signed the above form in
our presence. We, the undersigned, each being over 18 years of age, witness the principal´s
signature at the request and in the presence of the principal, and in the presence of each other,
on the day and year above set out.

Witnesses: Addresses:
______________________
_________________________
_________________________

______________________
_________________________
_________________________

Additional witness required when health care agency is signed in a hospital or skilled
nursing facility.

I hereby witness this health care agency and attest that I believe the principal to be of sound mind
and to have made this health care agency willingly and voluntarily.

Witness:_______________________
Attending Physician
Address:_______________________
_______________________

YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR
AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW . IF YOU INCLUDE SPECIMEN
SIGNATURES IN THIS POW ER OF ATTORNEY, YOU MUST COMPLETE THE
CERT IFICAT ION OPPOSITE THE SIGNATURES OF THE AGENTS.

I certify that the
signature of my agent
Specimen signatures of and successor(s) is
agent and successor(s) correct.

________________________ ________________________
(Agent) (Principal)

________________________ ________________________
(Successor agent) (Principal)

________________________ ________________________
(Successor agent) (Principal)’

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OFFICIAL CODE OF GEORGIA 31-36-10.
(a) The statutory health care power of attorney form contained in this
subsection may be used to grant an agent powers with respect to the
principal´s own health care; but the statutory health care power is not
intended to be exclusive or to cover delegation of a parent´s power to
control the health care of a minor child, and no provision of this chapter
shall be construed to bar use by the principal of any other or different form
of power of attorney for health care that complies with Code Section 31-36-
5. If a different form of power of attorney for health care is used, it may
contain any or all of the provisions set forth or referred to in the following
form. When a power of attorney in substantially the following form is used,
and notice substantially similar to that contained in the form below has
been provided to the patient, it shall have the same meaning and effect as
prescribed in this chapter. Substantially similar forms may include forms
from other states. The statutory health care power may be included in or
combined with any other form of power of attorney governing property or
other matters:

(b) The foregoing statutory health care power of attorney form authorizes,
and any different form of health care agency may authorize, the agent to
make any and all health care decisions on behalf of the principal which the
principal could make if present and under no disability, incapacity, or
incompetency, subject to any limitations on the granted powers that appear
on the face of the form, to be exercised in such manner as the agent
deems consistent with the intent and desires of the principal. The agent will
be under no duty to exercise granted powers or to assume control of or
responsibility for the principal´s health care; but, when granted powers are
exercised, the agent will be required to use due care to act for the benefit
of the principal in accordance with the terms of the statutory health care
power and will be liable for negligent exercise. The agent may act in
person or through others reasonably employed by the agent for that
purpose but may not delegate authority to make health care decisions. The
agent may sign and deliver all instruments, negotiate and enter into all
agreements, and do all other acts reasonably necessary to implement the
exercise of the powers granted to the agent. Without limiting the generality
of the foregoing, the statutory health care power form shall, and any
different form of health care agency may, include the following powers,
subject to any limitations appearing on the face of the form:
(1) The agent is authorized to consent to and authorize or refuse, or to
withhold or withdraw consent to, any and all types of medical care,
treatment, or procedures relating to the physical or mental health of the
principal, including any medication program, surgical procedures, life-
sustaining or death-delaying treatment, or provision of nourishment and

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fluids for the principal, but not including psychosurgery, sterilization, or
involuntary hospitalization or treatment covered by Title 37;
(2) The agent is authorized to admit the principal to or discharge the
principal from any and all types of hospitals, institutions, homes, residential
or nursing facilities, treatment centers, and other health care institutions
providing personal care or treatment for any type of physical or mental
condition, but not including psychosurgery, sterilization, or involuntary
hospitalization or treatment covered by Title 37;
(3) The agent is authorized to contract for any and all types of health care
services and facilities in the name of and on behalf of the principal and to
bind the principal to pay for all such services and facilities, and the agent
shall not be personally liable for any services or care contracted for on
behalf of the principal;
(4) At the principal´s expense and subject to reasonable rules of the health
care provider to prevent disruption of the principal´s health care, the agent
shall have the same right the principal has to examine and copy and
consent to disclosure of all the principal´s medical records that the agent
deems relevant to the exercise of the agent´s powers, whether the records
relate to mental health or any other medical condition and whether they are
in the possession of or maintained by any physician, psychiatrist,
psychologist, therapist, hospital, nursing home, or other health care
provider, notwithstanding the provisions of any statute or other rule of law
to the contrary; and
(5) The agent is authorized to direct that an autopsy of the principal´s body
be made; to make a disposition of any part or all of the principal´s body
pursuant to Article 6 of Chapter 5 of Title 44, the ‘Georgia Anatomical Gift
Act,’ as now or hereafter amended ; and to direct the disposition of the
principal´s remains.


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