Fillable Printable Statutory Short Form Durable Power of Attorney for Health Care - Georgia

Statutory Short Form Durable Power of Attorney for Health Care - Georgia

‘GEORGIA STATUTORY SHORT FORM

DURABLE POWER OF ATTORNEY FOR HEALTH CARE’

31-36-10

NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE

PERSON YOU DESIGNATE (YOUR AGENT) BROAD POWERS TO MAKE

HEALTH CARE DECISIONS FOR YOU, INC LUDING POWER TO REQUIRE,

CONSENT TO, OR WITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL

TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND T O ADMIT

YOU TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME, OR OTHER

INSTITUTION; BUT NOT INCLUDING PSYCHOSURGERY, STERILIZATION, OR

INVOLUNTARY HOSPITALIZATI ON OR TREATMENT COVE RED BY TITLE 37

OF THE OFFICIAL CODE OF GEORGIA ANNOTATED. THIS FORM DOES NOT

IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT,

WHEN A POWER IS EXERCISED, YOUR AGENT WILL HAVE TO USE DUE

CARE TO ACT FOR YOUR BENEFIT AND IN AC CORDANCE WITH THIS FORM.

A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS THE

AGENT IS NOT ACTING PROPERLY. YOU MAY NAME COAGENTS AND

SUCCESSOR AGENTS UNDER THIS FORM, BUT YOU MAY NOT NAME A

HEALTH CARE PROVIDER WHO MAY BE DIRECTLY OR INDIRECTLY

INVOLVED IN RENDERING HEALTH CARE TO YOU UNDER THIS POWER.

UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN THE

MANNER PROVIDED BELOW OR UNTIL YOU REVOKE THIS POWER OR A

COURT ACTING ON YOUR BEHALF TERMI NATES IT, YOUR AGENT MAY

EXERCISE THE POWERS GIVEN IN THIS PO WER THROUGHOUT YOUR

LIFETIME, EVEN AFTER YOU BECOME DI SABLED, INCAPACITATED, OR

INCOMPETENT. THE POWERS YOU GIVE YOUR AGE NT, YOUR RIGHT TO

REVOKE THOSE POWERS, AND THE PENALTIES FOR VIOLATING THE LAW

ARE EXPLAINED MORE FULLY IN CODE SECTIONS 31-36-6, 31-36-9, AND 31-

36-10 OF THE GEORGIA "DURABLE POWER OF ATTORNEY FOR HEALTH

CARE ACT" OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS

FORM). THAT ACT EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM

OF POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS ANYTHING

ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A

LAWYER TO EXPLAIN IT TO YOU.

DURABLE POWER OF ATTORNEY made this _____ day of ______________, ____.

1. I, _________________________________________________________________

(insert name and address of principal)

hereby appoint ________________________________________________________

(insert name and address of agent)

as my attorney in fact (my agent) to act for me and in my name in any way I could act in

person to make any and all decisions for me concerning my personal care, medical

treatment, hospitalization, and health care and to require, withhold, or withdraw any type

of medical treatment or procedure, even though my death may ensue. My agent shall

have the same access to my medical records that I have, including the right to disclose the

contents to others. My agent shall also have full power to make a disposition of any part

or all of my body for medical purposes, authorize an autopsy of my body, and direct the

disposition of my remains.

THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE

SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY DE CISION

YOU COULD MAKE TO OBTAI N OR TERMINATE ANY TYPE OF HEALTH

CARE, INCLUDING WITHDRAWAL OF NOURISHMENT AND FLUIDS AND

OTHER LIFE-SUSTAINING OR DEATH-DELAYING MEASURES, IF YOUR

AGENT BELIEVES SUCH ACTION WOULD BE CONSISTENT WITH YOUR

INTENT AND DESIRES. IF YOU WISH TO LIMIT THE SCOPE OF YOUR

AGENT´S POWERS OR PRES CRIBE SPECIAL RULES TO LIMIT THE POWER TO

MAKE AN ANATOMICAL GIFT, AUTHORIZE AUT OPSY, OR DISPOSE OF

REMAINS, YOU MAY DO S O IN TH E FOLLOWING PARAGRAPHS.

2. The powers granted above shall not include the following powers or shall be subject to

the following rules or limitations (here you may include any specific limitations you

deem appropriate, such as your own definition of when life-sustaining or death-delaying

measures should be withheld; a direction to continue nourishment and fluids or other life-

sustaining or death-delaying treatment in all events; or instructions to refuse any specific

types of treatment that are inconsistent with your religious beliefs or unacceptable to you

for any other reason, such as blood transfusion, electroconvulsive therapy, or

amputation):

______________________________________________________________________

THE SUBJECT OF LIFE-SUSTAINING OR DEATH-DEL AYING TREATMENT IS

OF PARTICULAR IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING

WITH THAT SUBJECT, SOME GENERAL STATEMENTS CONCERNING THE

WITHHOLDING OR REMOVAL OF LIFE-SUSTAINING OR DEATH-DELAYING

TREATMENT ARE SET FORTH BELOW. IF YOU AGR EE WITH ONE OF THESE

STATEMENTS, YOU MAY INITIAL THAT STATEMENT, BUT DO NOT INITIAL

MORE THAN ONE:

I do not want my life to be prolonged nor do I want life-sustaining or death-delaying

treatment to be provided or continued if my agent believes the burdens of the treatment

outweigh the expected benefits. I want my agent to consider the relief of suffering, the

expense involved, and the quality as well as the possible extension of my life in making

decisions concerning life-sustaining or death-delaying treatment.

Initialed ______

I want my life to be prolonged and I want life-sustaining or death-delaying treatment to

be provided or continued unless I am in a coma, including a persistent vegetative state,

which my attending physician believes to be irreversible, in accordance with reasonable

medical standards at the time of reference. If and when I have suffered such an

irreversible coma, I want life-sustaining or death-delaying treatm ent to be withheld or

discontinued.

Initialed ______

I want my life to be prolonged to the greatest extent possible without regard to my

condition, the chances I have for recovery, or the cost of the procedures.

Initialed ______

THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU AT

ANY TIME AND IN ANY MANNER WHILE YOU ARE ABLE T O DO S O. IN THE

ABSENCE OF AN AMENDMENT OR REVOCATION, THE AUTHORITY

GRANTED IN THIS POWER OF ATTORNEY WI LL BECOME EFFECTIVE AT THE

TIME THIS POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH

AND WILL CONTINUE BEYOND YOUR DEATH IF ANATOMICAL GIFT,

AUTOPSY, OR DISPOSITION OF RE MAINS IS AUTHORIZED, UNLESS A

LIMITATION ON THE BEGINNING DATE OR DURATION IS MADE BY

INITIALING AND COMPLETING EITHER OR BOTH OF THE FOLLOWING:

3. ( ) This power of attorney shall become effective on ________________________

(insert a future date or event during your lifetime, such as court determination of your

disability, incapacity, or incompetency, when you want this power to first take effect).

4. ( ) This power of attorney shall terminate on _______________________ (insert a

future date or event, such as court determination of your disability, incapacity, or

incompetency, when you want this power to terminate prior to your death).

IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND

ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH:

5. If any agent named by me shall die, become legally disabled, incapacitated, or

incompetent, or resign, refuse to act, or be unavailable, I name the following (each to act

successively in the order named) as successors to such agent:

___________________________________________________________________

IF YOU WISH TO NAME A GUARDIAN OF YOUR PER SON IN THE EVENT A

COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU MAY, BUT ARE

NOT REQUIRED TO, DO SO BY INSERTING THE NAME OF SUCH GUARDIAN

IN THE FOLLOWING PARAGRAPH. THE COURT WILL APPOINT THE PERSON

NOMINATED BY YOU IF THE COURT FINDS THAT SUCH APPOINTMENT

WILL SERVE YOUR BEST INTERESTS AND WELFARE. YOU MAY, BUT ARE

NOT REQUIRED TO, NOMINATE AS YOUR GUARDIAN THE SAME PERSON

NAMED IN THIS FORM AS YOUR AGENT.

6. If a guardian of my person is to be appointed, I nominate the following to serve as such

guardian: _______________________________________________________________

(insert name and address of nominated guardian of the person)

7. I am fully informed as to all the contents of this form and understand the full import of

this grant of powers to my agent.

Signed _______________________

(Principal)

The principal has had an opportunity to read the above form and has signed the above

form in our presence. We, the undersigned, each being over 1 8 years of age, witness the

principal´s signature at the request and in the presence of the principal, and in the

presence of each other, on the day and year above set out.

Witnesses: Addresses:

______________________ _________________________

_________________________

______________________ _________________________

_________________________

Additional witness required when health care agency is signed in a hospital or skilled

nursing facility.

I hereby witness this health care agency and attest that I believe the principal to be of

sound mind and to have made this health care agency willingly and voluntarily.

Witness:_______________________

Attending Physician_______________________

Address:_______________________

YOU MAY, BUT ARE NOT REQUIRED TO, REQUES T YOUR AGENT AND

SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU

INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU

MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE

AGENTS.

I certify that the signature of my agent

Specimen signatures of and successor(s) is

agent and successor(s) correct.

________________________ ________________________

(Agent) (Principal)

________________________ ________________________

(Successor agent) (Principal)

________________________ ________________________

(Successor agent) (Principal)

The foregoing statutory health care power of attorney form authorizes, and any different

form of health care agency may authorize, the agent to make any and all health care

decisions on behalf of the principal which the principal could make if present and under

no disability, incapacity, or incompetency, subject to any limitations on the granted

powers that appear on the face of the form, to be exercised in such manner as the agent

deems consistent with the intent and desires of the principal. The agent will be under no

duty to exercise granted powers or to assume control of or responsibility for the

principal´s health care; but, when granted powers are exercised, the agen t will be required

to use due care to act for the benefit of the principal in accordance with the terms of the

statutory health care power and will be liable for negligent exercise. The agent may act in

person or through others reasonably employed by the agent for that purpose but may not

delegate authority to make health care decisions. The agent may sign and deliver all

instruments, negotiate and enter into all agreements, and do all other acts reasonably

necessary to implement the exercise of the powers granted to the agent. Without limiting

the generality of the foregoing, the statutory health care power form shall, and any

different form of health care agency may, include the following powers, subject to any

limitations appearing on th e face of the form:

(1) The agent is authorized to consent to and authorize or refuse, or to withhold or

withdraw consent to, any and all types of medical care, treatment, or procedures relating

to the physical or mental health of the principal, including any medication program,

surgical procedures, life-sustaining or death-delaying treatment, or provision of

nourishment and fluids for the principal, but not including psychosurgery, sterilization, or

involuntary hospitalization or treatment covered by Title 37;

(2) The agent is authorized to admit the principal to or discharge the principal from any

and all types of hospitals, institutions, homes, residential or nursing facilities, treatment

centers, and other health care institutions providing personal care or treatment for any

type of physical or mental condition, but not including psychosurgery, sterilization, or

involuntary hospitalization or treatment covered by Title 37;

(3) The agent is authorized to contract for any and all types of health care services and

facilities in the name of and on behalf of the principal and to bind the principal to pay for

all such services and facilities, and the agent shall not be personally liable for any

services or care contracted for on behalf of the principal;

(4) At the principal´s expense and subject to reasonable rules of the health care provider

to prevent disruption of the principal´s health care, the agent shall have the same right the

principal has to examine and copy and consent to disclosure of all the principal´s medical

records that the agent deems relevant to the exercise of the agent´s powers, whether the

records relate to mental health or any other medical condition and whether they are in the

possession of or maintained by any physician, psychiatrist, psychologist, therapist,

hospital, nursing home, or other health care provider, notwithstanding the provisions of

any statute or other rule of law to the contrary; and

(5) The agent is authorized to direct that an autop sy of the principal´s body be made; to

make a disposition of any part or all of the principal´s body pursuant to Article 6 of

Chapter 5 of Title 44, the 'Georgia Anatomical Gift Act,' as now or hereafter amended;

and to direct the disposition of the principal´s remains.