Georgia Advance Directive For Health Care (Page 2 of 6) in pdf

2. Back-Up Health Care Agent

This section is optional. PART ONE will be effective even if this section is left blank.

If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable

efforts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent,

then I select the following, each to act successively in the order named, as my back-up health care agent(s):

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

3. General Powers of Health Care Agent

My health care agent will make health care decisions for me when I am unable to communicate my health care

decisions or I choose to have my health care agent communicate my health care decisions.

My health care agent will have the same authority to make any health care decision that I could make. My health care

agent´s authority includes, for example, the power to:

•

Admit me to or discharge me from any hospital, skilled nursing facility, hospice, or other health care facility or

service;

•

Request, consent to, withhold, or withdraw any type of health care; and

•

Contract for any health care facility or service for me, and to obligate me to pay for these services (and my health

care agent will not be financially liable for any services or care contracted for me or on my behalf).

My health care agent will be my personal representative for all purposes of federal or state law related to privacy of

medical records (including the Health Insurance Portability and Accountability Act of 1996) and will have the same

access to my medical records that I have and can disclose the contents of my medical records to others for my

ongoing health care.

My health care agent may accompany me in an ambulance or air ambulance if in the opinion of the ambulance

personnel protocol permits a passenger and my health care agent may visit or consult with me in person while I am

in a hospital, skilled nursing facility, hospice, or other health care facility or service if its protocol permits visitation.

My health care agent may present a copy of this advance directive for health care in lieu of the original and the copy

will have the same meaning and effect as the original.

I understand that under Georgia law:

•

My health care agent may refuse to act as my health care agent;

•

A court can take away the powers of my health care agent if it finds that my health care agent is not acting

properly; and

•

My health care agent does not have the power to make health care decisions for me regarding psychosurgery,

sterilization, or treatment or involuntary hospitalization for mental or emotional illness, mental retardation, or

addictive disease.

4. Guidance for Health Care Agent

When making health care decisions for me, my health care agent should think about what action would be consistent

with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART

TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the

past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health

care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances

and treatment options.

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Georgia Advance Directive For Health Care Page 2

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