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Durable Power Of Attorney For Health Care (Georgia) POA-GA 100 - Legal Forms
| Durable Power Of Attorney For Health Care (Georgia) Form. This is a Legal Forms form and can be used in Health Care-Living Wills Power Of Attorney . |
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GEORGIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE Pursuant to Georgia Code Title 31 Sec 31-36-1 this DURABLE day of , POWER OF ATTORNEY made this 20 . I, (Insert name and address of principal) , hereby appoint as my attorney in fact (my agent) to act for me 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. 1. The powers granted above shall not include the following powers or shall be subject to the following rules or limitations: THE SUBJECT OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT IS OF PARTICULAR IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, SOME GENERAL STATEMENTS CONCERNNG THE WITHHOLDING OR REMOVAL OF LIFE-SUSTAINING OR DEATH-DELAYING TREATMENT ARE SET FORTH BELOW. IF YOU AGREE WITH ONE OF THESE STATEMENTS, YOU MAY INITIAL THAT STATEMENT, BUT DO NOT INITIAL MORE THAN ONE: 2. 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 deathdelaying 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 treatment 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 TO DO SO. IN THE ABSENCE OF AN AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY WILL 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 REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF THE FOLLOWING: 3. attorney shall become effective on (a future date or event during your lifetime when you want this power to first take effect). (a ( ) This power of attorney shall terminate on 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 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: 1) 2) ( ) This power of 4. 5. IF YOU WISH TO NAME A GUARDIAN OF YOUR PERSON 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 (Continued on back) 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 importance of this grant of powers to my agent. Signed (Principal) (OPTIONAL) I specifically provide that if I have executed a Living Will on or after April 16, 1992, under O.C.GA. Chapter 32, Title 31, that the Living Will will be of full force even if there continues to be an agent available to serve pursuant to this Durable Power of Attorney for Healthcare. Both the Living Will and the Durable Power of Attorney for Healthcare shall be valid except to the extent that my wishes pursuant to the Living Will are contrary to the decisions made by the agent appointed in this document, in which case the Living Will shall take precedence. 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 18 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: Phone No:________________________ Phone No: 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, REQUEST YOUR AGENT AND SUCCESSOR AGENTS TO PROVIDE SPECIMAN SIGNATURES BELOW. IF YOU INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE AGENTS. Specimen signatures of certify that the signature of Agent and successor(s) my agent and successor(s) is correct. (Successors Agent) (Successors Agent) (Successors Agent) (Principal) (Principal) (Principal) American LegalNet, Inc. © www.FormsWorkFlow.com
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