Georgia Advanced Directives For Health Care Form (Page 2 of 9) in pdf

Georgia Advanced Directives For Health Care Form Page 2

You may rarcke this completedform at any time. This completedfann

will replace any advance

directivefor health care, durable power of attorneyfor heatth care,

health care prory, or living will

that you have completed before completing thisfirtn.

PART ONE: HEALTTI CARE AGENT

IPART oNE will be effective even if PART TWo is not completed. A physician or heatth

care

provider who is directly involved in your

-health

care may not serve as your heakh

"nn

ogi,t. tfi",

are married, a future divorce orr annulment of your marriage wili

revoke the selecio"

"i;;;

cuwemt spcuse as your-health care agent. Ifyou are not married, afuture

marriagewill revoke the

selection ofyour health care agent unless ihL p"r"o, yeu seleeted * yoo,

h"alth care agmt ts your

new spouse.J

(I)

HEALTE CARE AGENT

I select the following perqon as my health care agent to make health care

decisioni for me:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

Q'' BACK-UP EEALTII CARE AGENT

tThis section is optional. PART ONE will be effective even if this section is left btank.J

ffmy heal-th care agent cannot be contacted in a reasonabie time period

and cannot be located with

reasonable efforts or for anyreason my hefth care agent is unavailable

or unable or unwilling to uc1

as my health care agen! then I select the following, each to act successively

in the order named as

my backup health care agent(s):

Name:

Address:

Telephone Numbers:

(Home, Worh and Mobile)

Page 2 of9 pages.

Georgia Advanced Directives For Health Care Form Page 2