Georgia Medical Power of Attorney Form

The Georgia medical power of attorney form is a legal document which allows you (the Principal) to authorize another person (an Attorney In Fact or Agent) to act on your behalf in matters that relate to your personal care, any medical treatment, hospitalization or health care. These powers include an authorization to require, withhold, or withdraw any type of medical treatment or procedure that you would feel unnecessary depending upon your medical condition. This document is called “durable” because it will continue to be effective (and in some cases can only be effective) upon your disability, incapacity and/or incompetency. Unlike a living will, which generally only applies to end of life decision making, these particular powers may apply to a number of lesser and non-life threatening situations in which medical care decisions will be necessary. (See Georgia Code Section 31-36-1)

How To Write

Step 1 – Begin by downloading the document and reviewing page one.

Step 2 – On page 2 Section 1, provide the following information:

  • Date the document is being created in dd/mm/yyyy format
  • In the first line of the paragraph, enter the name and address of principal
  • In line 2 of the paragraph, enter the name and address of agent who will be assisting with healthcare decisions for the principal
  • Continue to read all of the paragraphs to better educate yourself with regard to what you should expect

Step 3 – Section 2 – If you have specific rules, additions or limitations, type or print them into the lines provided on the form

  • Continue to read all paragraphs as you continue

Step 4 – Life Sustaining or Death Delaying Subjects – If you would like to address your wishes for how your medical care is handled by your agent and your medical team, initial the lines next to the following statements that apply to you:

  • 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.
  • 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.
  • 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.

Step 5 – Section 3 – Enter the date in which you would like the document to go into effect in mm/dd/yyyy format

  • Section 4 – Enter the date in which you would like the document to no longer be in effect or end
  • Section 5 – This section will allow you to provide the name(s) of any Successor Agents you may wish to take over your medical care in the event your original Agent becomes unable or unwilling to continue making decisions for you – Simply write or type the name(s) into the lines
  • Section 6 – If you would like to name a guardian of your person, enter the name into the line provided on the form
  • Section 7 – Read the statement. If you are in agreement, provide your (the Principal’s) signature on the signature line provided

Step 6 – Witness Signatures – In this section you will be required to provide the signatures of two witnesses. Make certain that the witnesses read the statement. They would then, each one, provide:

  • Provide the names of your witnesses on the lines provided
  • Provide the addresses of your witnesses on the address lines provided

Step 7 – If you’re in a skilled nursing facility – You will require a third witness to attest to the fact that you are signing the document willingly and with sound mind. They must provide:

  • The signature of the witness
  • The name of the attending physician
  • The address of the facility

Step 8 – (OPTIONAL) – If you would like your Agent and Successor Agent(s) to provide specimen signatures, you must sign next to each of their signature to attest that you have seen them sign provide the specimen signatures

  • The remaining information should be reviewed by the principal. If at any point you have legal questions, you may consult with an attorney of your choice.
  • This document may be revoked at any time, in writing from the principal to the agent or successor, as long as the principal is competent to do so
  • Make copies of this document to provide to all who have signed this document for your records and theirs
  • Provide the original to your agent