Georgia Advance Directive For Health Care (Page 7 of 14) in pdf

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. 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.

5. Powers of Health Care Agent After Death

A. AUTOPSY

My Health Care Agent will have the power to authorize an autopsy of my body unless I have limited my Health

Care Agent’s power by initialing below.

__________ My Health Care Agent will not have the power to authorize an autopsy of my body

(Initials)

(unless an autopsy is required by law).

B. Organ Donation and Donation of Body

My Health Care Agent will have the power to make a disposition of any part or all of my body for medical

purposes pursuant to the Georgia Anatomical Gift Act, unless I have limited my Health Care Agent’s power

by initialing below.

Initial each statement that you want to apply.

_________ My Health Care Agent will not have the power to make a disposition of my body for use in a

(Initials)

medical study program.

_________ My Health Care Agent will not have the power to donate any of my organs.

(Initials)

Georgia Advance Directive For Health Care Page 7