GEORGIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(“Healthcare Power of Attorney” or “HPOA”)

This template is designed to comply with the Georgia Advance Directive for Health Care Act, O.C.G.A. § 31-32-1 et seq., and with the privacy requirements of the Health Insurance Portability and Accountability Act, 45 C.F.R. §§ 164.502, 164.508.
[// GUIDANCE: Insert client-specific information in all bracketed placeholders and delete guidance boxes before finalization.]

TABLE OF CONTENTS

1. Document Header .......................................................... 1
2. Definitions ............................................................... 2
3. Operative Provisions ...................................................... 4
4. Representations & Warranties .............................................. 9
5. Covenants & Restrictions .................................................. 9
6. Default & Remedies ........................................................ 10
7. Risk Allocation ........................................................... 11
8. Dispute Resolution ........................................................ 12
9. General Provisions ........................................................ 12
10. Execution Block .......................................................... 14

Page numbers will auto-adjust in final word-processing format.

1. DOCUMENT HEADER

1.1 Parties

a. Principal: [PRINCIPAL FULL LEGAL NAME], residing at [PRINCIPAL ADDRESS] (“Principal”).
b. Agent: [PRIMARY AGENT FULL LEGAL NAME], residing at [PRIMARY AGENT ADDRESS] (“Agent”).
c. Alternate Agent(s) (optional):
i. [ALTERNATE AGENT 1 NAME & ADDRESS]
ii. [ALTERNATE AGENT 2 NAME & ADDRESS]

1.2 Recitals

A. Principal desires to appoint an Agent to make health-care decisions on Principal’s behalf should Principal lack capacity to do so.
B. This instrument is intended to be a “durable power of attorney for health care” and an “advance directive for health care” within the meaning of O.C.G.A. § 31-32-1 et seq.
C. Principal further desires to authorize release of protected health information to Agent pursuant to 45 C.F.R. §§ 164.502, 164.508.
D. Consideration is acknowledged by the mutual promises herein and the reliance of health-care providers on this document.

1.3 Effective Date & Durability

This HPOA is effective on the earlier of (i) the date of incapacity as determined under Section 3.4, or (ii) [EFFECTIVE DATE IF IMMEDIATE], and shall remain in effect until revoked pursuant to Section 6.1.

1.4 Governing Law & Jurisdiction

This HPOA is governed by the health-care laws of the State of Georgia (“State”), and any proceeding relating to its construction or enforcement shall be filed exclusively in the [COUNTY] Probate Court of the State of Georgia.

2. DEFINITIONS

For ease of reference, capitalized terms are defined alphabetically below. Terms used but not defined have the meanings given under O.C.G.A. § 31-32-2.

“Advance Directive” – This document, inclusive of any properly executed amendments or restatements.

“Agent” – The individual(s) named in Section 1.1(b)-(c) who are authorized to act for the Principal under this Advance Directive.

“Capacity” – Principal’s ability to understand the nature and consequences of a proposed health-care decision, as determined under Section 3.4.

“End-of-Life Decision” – Any decision regarding life-prolonging or palliative treatment, including but not limited to mechanical ventilation, artificial nutrition and hydration, cardiopulmonary resuscitation (“CPR”), dialysis, or similar interventions.

“Good Faith” – Honesty in fact and the observance of reasonable standards of health-care decision-making at the time of performance.

“Health-Care Provider” – Any person licensed, certified, or otherwise authorized to administer health-care in Georgia.

“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and implementing regulations, 45 C.F.R. Parts 160 & 164.

“Incapacity” – A determination that the Principal lacks Capacity within the meaning of O.C.G.A. § 31-32-2(7).

“Principal” – The individual granting authority under this Advance Directive.

“Protected Health Information” or “PHI” – Information defined under 45 C.F.R. § 160.103.

“Successor Agent” – Any Alternate Agent who assumes authority in accordance with Section 6.2.

3. OPERATIVE PROVISIONS

3.1 Appointment & Priority of Agents

a. Principal hereby appoints the Agent to make health-care decisions on Principal’s behalf when Principal lacks Capacity.
b. If the Agent resigns, is unavailable, or is unable to act, the Alternate Agent(s) shall serve in the order listed in Section 1.1(c).
c. Co-agents are not authorized unless expressly stated: [SELECT ONE] ☐ Co-agents may act jointly ☐ Co-agents may act independently ☒ Co-agents not permitted.

[// GUIDANCE: Retain only the applicable checkbox above.]

3.2 Scope of Authority

Subject to the limitations herein, Agent may:

1. Consent, refuse, or withdraw consent to medical or surgical procedures, diagnostic tests, and all forms of health-care.
2. Make End-of-Life Decisions in accordance with Section 3.3.
3. Access, request, receive, and disclose PHI to the same extent Principal could, consistent with Section 3.6.
4. Hire and fire health-care providers; choose medical facilities; authorize admissions to or discharges from hospitals, hospice, or nursing homes.
5. Execute waivers, consents, and releases relative to insurance, Medicare/Medicaid, or other payment matters.
6. Apply for public benefits to defray the cost of care.
7. Take any lawful action necessary to implement health-care decisions, including signing required documents and releases.

3.3 End-of-Life Provisions

a. General Preference: [SELECT ONE]
☐ I wish to prolong life as long as possible within generally accepted health-care standards.
☐ I do NOT wish to receive life-prolonging treatment if my attending physician and one additional physician certify that:
i. I have a terminal condition; or
ii. I am permanently unconscious; or
iii. The burden of treatment outweighs the expected benefit.
b. Specific Interventions (check all that apply):
☐ CPR
☐ Mechanical Ventilation
☐ Artificial Nutrition/Hydration
☐ Dialysis
☐ Antibiotics
☐ Pain Relief Even if Hastening Death
c. Organ Donation: [SELECT ONE] ☐ Yes ☐ No ☐ Limited to the following organs/tissues: [SPECIFY].

[// GUIDANCE: Georgia law requires that End-of-Life instructions be honored unless clearly revoked. Ensure consistency with any prior living wills.]

3.4 Determination of Incapacity

Incapacity shall be established by a written determination from (i) the attending physician and (ii) one additional physician or licensed psychologist, each acting within their scope of practice, and delivered to the Agent and supervising Health-Care Provider.

3.5 Effectiveness & Term

a. If “immediate” effectiveness is selected in Section 1.3, Agent’s authority begins on the Effective Date and continues notwithstanding Principal’s Capacity.
b. If “springing” effectiveness is selected, Agent’s authority commences upon a determination of Incapacity under Section 3.4.
c. Authority terminates upon the first to occur of: (i) revocation under Section 6.1; (ii) Principal’s death (except as to autopsy, disposition of remains, and organ donation decisions); or (iii) as otherwise mandated by law.

3.6 HIPAA Authorization

Principal authorizes any Health-Care Provider, insurer, or HIPAA-covered entity to disclose PHI to the Agent to the fullest extent permitted under 45 C.F.R. § 164.502(g). This authorization survives Principal’s death to the extent necessary for post-mortem decisions authorized herein.

3.7 Nomination of Guardian

Should a guardianship proceeding become necessary, Principal nominates the Agent as guardian of the person pursuant to O.C.G.A. § 31-32-4(b). The probate court is requested, but not required, to honor this nomination.

3.8 Reliance by Third Parties

Any third party may rely conclusively on a photocopy or electronically transmitted copy of this Advance Directive without liability, and such third party is indemnified under Section 7.1 for Good Faith reliance.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal represents that:
a. Principal is at least 18 years of age, of sound mind, and under no duress or undue influence.
b. This instrument revokes any prior durable power of attorney for health care executed by Principal, except [SPECIFY PRIOR DOCUMENTS IF ANY].
c. Information provided herein is accurate as of the Effective Date.

4.2 Agent represents and warrants, by accepting appointment, that:
a. Agent is at least 18 years of age and competent to serve.
b. Agent will act in Good Faith and in accordance with the Principal’s known wishes or, if unknown, in the Principal’s best interests.
c. Agent is not currently subject to any order of protection that would affect eligibility to serve.

5. COVENANTS & RESTRICTIONS

5.1 Agent covenants to:
a. Consult with Health-Care Providers to the fullest extent practicable before making decisions.
b. Maintain contemporaneous records of significant health-care decisions.
c. Provide prompt notice to interested persons designated by Principal in Schedule A.

5.2 Restrictions on Agent’s Authority:
a. Agent may not consent to psychosurgery, involuntary sterilization, or experimental treatments unless expressly authorized in Schedule B.
b. Agent may not execute or revoke the Principal’s Last Will and Testament or other estate-planning documents.
c. Agent shall not receive compensation other than reasonable out-of-pocket expenses unless compensation terms are stated in Schedule C.

6. DEFAULT & REMEDIES

6.1 Revocation by Principal

Principal may revoke this Advance Directive in whole or in part at any time by:
a. A signed writing;
b. An oral statement in the presence of two adult witnesses;
c. Physical destruction of the document with intent to revoke; or
d. Execution of a subsequent Advance Directive.

6.2 Resignation or Removal of Agent

a. Agent may resign by written notice to the Principal (if capable), Successor Agent, and attending physician.
b. Any interested person may petition the probate court to remove an Agent for breach of fiduciary duty, incapacity, or other good cause shown.

6.3 Successor Appointment

Upon resignation, removal, death, or incapacity of an Agent, the next-listed Alternate Agent shall automatically become the Agent without further action.

6.4 Remedies

In addition to statutory remedies, any willful violation of this Advance Directive may be enjoined by order of the State probate court. Monetary damages are limited under Section 7.2.

7. RISK ALLOCATION

7.1 Indemnification of Reliant Parties

Principal agrees to indemnify and hold harmless any Health-Care Provider or other third party who, in Good Faith, relies on this Advance Directive or on the representations of the Agent.

7.2 Limitation of Liability

No Agent shall be liable for exercising, or failing to exercise, powers hereunder if the Agent acts in Good Faith. In no event shall an Agent be liable for consequential, exemplary, or punitive damages.

7.3 Insurance (Optional)

[// GUIDANCE: Insert malpractice or liability insurance requirements here if the Principal desires the Agent to maintain coverage.]

7.4 Force Majeure

An Agent’s failure to act shall not constitute a breach if due to events beyond the Agent’s reasonable control, including unavailability of health-care facilities, natural disasters, or public health emergencies.

8. DISPUTE RESOLUTION

8.1 Governing Law: Georgia health-care law, as stated in Section 1.4.
8.2 Forum Selection: Exclusive jurisdiction and venue in the [COUNTY] Probate Court, State of Georgia.
8.3 Arbitration: Not available under the parties’ express agreement.
8.4 Jury Waiver: Not available; statutory probate procedures shall apply.
8.5 Injunctive Relief: Any party may seek injunctive relief to enforce health-care directives without posting bond.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver. Any amendment must meet the execution requirements of O.C.G.A. § 31-32-5. No waiver of rights under this document is valid unless in writing and signed by the waiving party.

9.2 Assignment & Delegation. Agent may not delegate authority except to a licensed Health-Care Provider for the limited purpose of executing an ordered treatment plan.

9.3 Successors & Assigns. The rights and obligations herein bind and inure to the benefit of the Principal’s and Agent’s respective heirs, executors, and assigns.

9.4 Severability. If any provision is adjudged invalid, the remaining provisions shall remain fully enforceable.

9.5 Integration. This document constitutes the entire agreement regarding the subject matter and supersedes all prior directives to the extent of any inconsistency.

9.6 Counterparts; Electronic Signatures. This Advance Directive may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

9.7 Delivery. An executed counterpart, including a digital copy, may be delivered to any Health-Care Provider and shall have the same force as the original.

10. EXECUTION BLOCK

I, [PRINCIPAL NAME], sign my name to this Durable Power of Attorney for Health Care on the ___ day of ____, 20__, at [CITY], Georgia.

[PRINCIPAL NAME], Principal

Statement of Witnesses
Each witness declares that the Principal is personally known to the witness, appears to be of sound mind and acting voluntarily, and is not being coerced or unduly influenced.

1. _____ Date: ____
   [WITNESS #1 NAME & ADDRESS]

2. _____ Date: ____
   [WITNESS #2 NAME & ADDRESS]

[// GUIDANCE: At least one witness must not be (i) a person who will knowingly inherit under the Principal’s will, (ii) the Agent or Alternate Agent, or (iii) a Health-Care Provider directly involved in the Principal’s care.]

Notary Acknowledgment (optional but recommended)

State of Georgia
County of ______

On this ___ day of ____, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], proved to me through satisfactory evidence of identification to be the person whose name is signed above and acknowledged the foregoing instrument.

Notary Public
My Commission Expires: ____

SCHEDULES (attach as needed)

• Schedule A – Persons to Receive Notice
• Schedule B – Experimental Treatment Authorization
• Schedule C – Agent Compensation Terms

[End of Document]