Georgia Medical Power of Attorney
This Medical Power of Attorney (“Document”) is created pursuant to the Georgia Advance Directive for Health Care Act, allowing an individual to appoint an agent to make health care decisions on their behalf in the event they become unable to do so. This Document grants the agent broad powers to make health care decisions following the principal's specific desires and limitations stated herein.
Principal Information:
- Full Name: ___________________________
- Address: ___________________________
- City: _____________________ State: Georgia Zip: ________
- Date of Birth: _________________
- Telephone Number: ___________________
Agent Information:
- Full Name: ___________________________
- Address: ___________________________
- City: _____________________ State: _________ Zip: ________
- Telephone Number: _____________________
Alternate Agent Information (Optional):
- Full Name: ___________________________
- Address: ___________________________
- City: _____________________ State: _________ Zip: ________
- Telephone Number: _____________________
In the event the originally designated agent is unable, unwilling, or ineligible to serve, the alternate agent will assume the role.
Health Care Decisions: The principal authorizes the agent to make any and all health care decisions on their behalf that the principal could make if able, including but not limited to:
- Consent or refusal of any medical treatment;
- Access to medical records necessary for decision-making;
- Decisions regarding autopsy and organ donation;
- Directives regarding life-sustaining treatment;
- Admission or discharge from medical facilities.
This authority is effective immediately and will continue in effect unless the principal becomes unable to make decisions for themselves, as determined by a physician.
Signatures:
This Document must be signed by the principal in the presence of two witnesses, who must also sign. The witnesses must not be the agent or alternate agent, related to the principal by blood or marriage, entitled to any portion of the principal's estate upon death, or directly financially responsible for the principal's medical care.
Principal's Signature: ___________________________ Date: _____________
Witness 1 Signature: ___________________________ Date: _____________
Witness 2 Signature: ___________________________ Date: _____________
Agent's Acknowledgement: I, ___________________(Agent's Name), hereby acknowledge that I have been appointed as an agent by the principal. I understand the responsibilities vested in me by this Document and agree to act in the best interests of the principal regarding their health care.
Agent's Signature: ___________________________ Date: _____________
Alternate Agent's Acknowledgement (if applicable): I, ___________________(Alternate Agent's Name), hereby acknowledge that I have been appointed as an alternate agent by the principal. I understand the responsibilities vested in me by this Document and agree to act in the best interests of the principal regarding their health care, should I be called upon to do so.
Alternate Agent's Signature: ___________________________ Date: _____________
Note: This Document does not authorize the agent to make financial decisions on behalf of the principal. For financial powers, a separate legal document is required.