Georgia Advance Directive For Health Care (Page 6 of 14) in pdf

Part One: Health Care Agent

PART ONE will be effective even if PART TWO is not completed. A physician or health care provider who is

directly involved in your health care may not serve as your Health Care Agent. If you are married, a future

divorce or annulment of your marriage will revoke the selection of your current spouse as your Health Care

Agent. If you are not married, a future marriage will revoke the selection of your Health Care Agent unless

the person you selected as your Health Care Agent is your new spouse.

1. Health Care Agent

I select the following person as my Health Care Agent to make health care decisions for me:

Name: _______________________________________________________________________

Address: ______________________________________________________________________

Telephone Numbers: _____________________________________________________________

(Home, Work, and Mobile)

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):

Back-up Health Care Agent #1:

Name: _______________________________________________________________________

Address: ______________________________________________________________________

Telephone Numbers: _____________________________________________________________

(Home, Work, and Mobile)

Back-up Health Care Agent #2:

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

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facility or service;

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

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

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(and my Health Care Agent will not be financially liable for any services or care contracted for me or

on my behalf).

Georgia Advance Directive For Health Care Page 6