Georgia Advance Directive For Health Care (Page 11 of 14) in pdf

Part Four: Effectiveness and Signatures

This advance directive for health care will become effective only if I am unable or choose not to make or

communicate my own health care decisions.

This form revokes any advance directive for health care, durable power of attorney for health care, health

care proxy, or living will that I have completed before this date.

Unless I have initialed below and have provided alternative future dates or events, this advance directive for

health care will become effective at the time I sign it and will remain effective until my death (and after my

death to the extent authorized in Section (5) of PART ONE).

_________ This advance directive for health care will become effective on or upon _______________

(Initials)

and will terminate on or upon _______________.

You must sign and date or acknowledge signing and dating this form in the presence of two witnesses. Both

witnesses must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be

together or present with you when you sign this form.

A witness:

Cannot be a person who was selected to be your Health Care Agent or back-up Health Care Agent in

■

PART ONE;

Cannot be a person who will knowingly inherit anything from you or otherwise knowingly gain a financial

■

benefit from your death; or

Cannot be a person who is directly involved in your health care.

■

Only one of the witnesses may be an employee, agent, or medical staff member of the hospital, skilled nursing

facility, hospice, or other health care facility in which you are receiving health care (but this witness cannot

be directly involved in your health care).

By signing below, I state that I am emotionally and mentally capable of making this advance directive for health

care and that I understand its purpose and effect.

_________________________________________________

_____________________

(Signature of Declarant)

(Date)

The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my per-

sonal observation, the declarant appeared to be emotionally and mentally capable of making this advance direc-

tive for health care and signed this form willingly and voluntarily.

_________________________________________________

_____________________

(Signature of First Witness)

(Date)

Print Name: ___________________________________________________________________

Address: _____________________________________________________________________

_________________________________________________

_____________________

(Signature of Second Witness)

(Date)

Print Name: ___________________________________________________________________

Address: _____________________________________________________________________

This form does not need to be notarized.

Georgia Advance Directive For Health Care Page 11

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