Georgia Advance Directive For Health Care
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14GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
By: _______________________________________ Date of Birth: __________
(Print Name)
(mm/dd/yyyy)
This advance directive for health care has four parts:
HEALTH CARE AGENT. This part allows you to choose
PART ONE
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. This document may be signed by you
or signed by someone else for you in your presence
and at your express direction.
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.
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