Friday, 9 June 2017

What is Advance Healthcare Directive with Universal Book Number

An advance healthcare directive, also known as living will, personal directiveadvance directivemedical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness. It must have Universal Book Number (UBN). 

Without Universal Book Numberadvance healthcare directive has No value. Universal Book Number can be purchased from UABN : Universal Agency for Book Number


How to buy UBN (Universal Book Number) for Advance Healthcare Directive Form
You should always buy UBN (Universal Book Number) for Advance Healthcare Directive Form from ubnenquiry@gmail.com UBN is Universal Book Number, the correct international identification of legal document.

For legal assistance Email us at    ubnenquiry@gmail.com

You should provide below information to get your UBN (Universal Book Number) for your Advance Healthcare Directive Form.-

Title of the Advance Healthcare Directive Form: ?

Publisher: Self Published/ Name of Publisher: ?

Advocate:
Author: ?

Language: ?

File Format:  ?

Place of Publication: ?

Contact Information of publisher: ?

Name of Country: ? 

E-Mail this information to ubnenquiry@gmail.com and UABN will deliver you the UBN for your Advance Healthcare Directive Form within approx 24 hours. Alternatively you can attach  " Advance Healthcare Directive Form" and apply for UBN from UABN. 


Legal Notice must contain UBN (Universal Book Number). It gives authoritative and official look to Legal Notice. UBN is correct identification of Legal Notice, it provides correct identity to your Legal Notice at international level, while you take the matter to court, attorney, judge, advocate, lawyers, and clients.

Now a days Corporates, Industries and individuals buys UBN (Universal Book Number) while they issue legal notices. The courts also pay adequate attention to notices with UBN (Universal Book Number).  It makes your case strong. Learned Advocate always advises their clients to have UBNUniversal Book Number should always be equipped with  Lease Deed , Rental Agreement,  contract, Power of attorney, Will Transfer.  Standard Law Firms always use UBN (Universal Book Number) to lease agreement to rent your residential home, apartment or condo.
Commercial Lease Deed or Commercial Rent Agreement gets a complete look when they have 
UBN (Universal Book Number). UBN (Universal Book Number) can be purchased from UABN  from ubnenquiry@gmail.com within 24 hours.

In modern world, no one want to take risk, failure and un-success, so as a precaution everybody buy UBN while they create Legal Documents & Forms. ‘Universal Book Number eradicates the chances of fraud in legal business and commitments. Some advocates do not buy ‘Universal Book Number’, for a legal document, to weaken the case, so clients should always remind and instruct the lawyer to buy the ‘Universal Book Number’ for their legal document. It is not expensive, but makes your legal agreement strong.

UBN is being used in following Legal items-

Advance Healthcare Directive with Universal Book Number
Codicil to Will with Universal Book Number
Cohabitation Agreement with Universal Book Number
Last Will and Testament with Universal Book Number
Living Will Medical with Universal Book Number
Power of Attorney with Universal Book Number
Power of Attorney with Universal Book Number
Deed of Trust with Universal Book Number
Eviction Notice with Universal Book Number
Home Lease Agreement with Universal Book Number
Land/Ground Lease Agreement with Universal Book Number
Late Rent Notice with Universal Book Number
Lease Agreement with Universal Book Number
Lease Amendment with Universal Book Number
Lease Application with Universal Book Number
Lease Renewal with Universal Book Number
Lease Termination with Universal Book Number
Mortgage Deed with Universal Book Number
Notice of Rent Increase with Universal Book Number
Notice to Quit with Universal Book Number
Notice to Vacate with Universal Book Number
Pet Addendum to a Lease Agreement with Universal Book Number
Quitclaim Deed with Universal Book Number
Rental Application with Universal Book Number
Roommate Agreement with Universal Book Number
Smoking Lease Addendum with Universal Book Number
Sublease Agreement with Universal Book Number
Tenant Removal Form with Universal Book Number
Vacation Rental Short Term Lease Agreement with Universal Book Number
Warranty Deed with Universal Book Number
Child Medical Consent with Universal Book Number
Child Travel Consent Form with Universal Book Number
Cohabitation Agreement with Universal Book Number
Divorce Agreement with Universal Book Number
IOU Last Will and Testament with Universal Book Number
Letter of Intent with Universal Book Number
Living Will with Universal Book Number
Medical Records with Universal Book Number
Release Form with Universal Book Number
Parenting Plan/Child Custody Agreement with Universal Book Number
Pet Care Agreement with Universal Book Number
Photo Release Form with Universal Book Number
Power of Attorney with Universal Book Number
Prenuptial Agreement with Universal Book Number
Purchase Agreement with Universal Book Number
Revocation of Power of Attorney with Universal Book Number
Roommate Agreement with Universal Book Number
Separation Agreement with Universal Book Number
IOU Loan Agreement with Universal Book Number
Power of Attorney with Universal Book Number
Promissory Note with Universal Book Number
Articles of Incorporation with Universal Book Number
Auto Bill of Sale with Universal Book Number
Bill of Sale with Universal Book Number
Boat Bill of Sale with Universal Book Number
Business Plan Template with Universal Book Number
Business Purchase Agreement with Universal Book Number
Cease and Desist Letter with Universal Book Number
Commercial Lease Agreement with Universal Book Number
Construction Contract Agreement with Universal Book Number
Deed of Trust with Universal Book Number
Employment Agreement with Universal Book Number
End User License Agreement with Universal Book Number
Firearm Bill of Sale Hold Harmless (Indemnity) Agreement with Universal Book Number
Horse Bill of Sale with Universal Book Number
Independent Contractor Agreement with Universal Book Number
Invoice with Universal Book Number
Joint Venture Agreement with Universal Book Number
Land/Ground Lease Agreement with Universal Book Number
Letter of Intent Licensing Agreement with Universal Book Number
Loan Agreement Non-Disclosure (Confidentiality) Agreement with Universal Book Number
Partnership Agreement with Universal Book Number
Partnership Agreement Amendment with Universal Book Number
Photo Release Form with Universal Book Number
Privacy Policy with Universal Book Number
Promissory Note with Universal Book Number
Purchase Order with Universal Book Number
Quitclaim Deed Release of Liability Form (Waiver of Liability) with Universal Book Number
Revocation of Power of Attorney with Universal Book Number
Sales Agreement Stock Certificate with Universal Book Number
Terms of Use Agreement with Universal Book Number
Trademark Assignment Agreement with Universal Book Number
Video Release Form with Universal Book Number
Warranty Deed with Universal Book Number
Copyright Form Agreement with Universal Book Number
Royalty Agreement Form with Universal Book Number 
Company Press Releases Form with Universal Book Number

Secrets of Legal Documents
Terms and conditions should be set very clearly. Clients should pay attention that even a single line of ‘Terms and conditions’ in above document can affect the whole legal agreement, so read clearly before you sign it. If you are uncomfortable with any terms/ condition ask to strike that straighford, otherwise it will tense you in future. Check carefully Legal Documents/ Notice/ Agreement must have ‘Universal Book Number. Always refer ‘Universal Book Number, while you correspond / issue legal notices with your advocate/ legal consultant or client. Similarly, if you are replying to a notice, agreement or contract, first get ‘Universal Book Number from UABN : ubnenquiry@gmail.com , within 24 hours it will be with you. Then mention it on your legal document and issue it. You can also ask UABN (ubnenquiry@gmail.com ) to publish your legal document electronically at international level.

UBN costs US$ 100. Different formats of publication and publication in different languages need different UBN, but these all UBNs are provided at No additional cost. So if you publish a document in two languages and two formats e.g. print and online, you will be provided 4 UBNs at just US$ 100. If you publish the same document in pdf, HTML, JPEG, you will be provided extra UBNs at No additional cost.
UABNUniversal Agency for Book Number; officially assigns and regulates legitimate UBN. It is responsible for the collection, description, preservation and accessibility of UBN. The UABN also serves as a development centre for the literature and library sector and promotes strong cooperation in the field, on not for profit status.
UBN: Universal Book Number
UBN is Universal Book Number?

UBN is a unique identification number for a book. Universal Book Number is recognized globally and catalyzes the sale of book to bookstores and libraries. UBN allows scientifically management of books and their discoverability at global level. Universal Book Number eliminates the ambiguity in identification of books. While numerous book titles, published by different publishers may have same titles across the world, it creates huge confusion among readers. UBN serves here as a great tool to correctly identify a book. Since all such books will carry different UBN. UBN is assigned to international as well as local editions of books. If edition of a book is changed, (e.g. next edition) it would require new UBN. If content is same, it needs to assign different UBN for print and/ electronic version, at free of cost. UBN is affected by format of file (e.g. jpeg, MS-Word, PDF, etc). A book in different languages needs to be assigned separate UBN, at free of cost. N (any) number of copies may be produced for a book, assigned with single UBN.

Example of UBN:  UBN is 15 digit numeric code. E.g.- 015-346724641726

Buy/ Purchase UBN
UBN can be demanded either by authors, self publishers or publishers. Readers may ask about UBN for a book which they want to read, download, buy, tell a friend, inquire, or review. It helps to increase the chances of sales of books, and royalty earned by authors and publishers along with publicity. UBN is assigned for literature standardization, and is a not for profit activity. UBN costs US$ 100. Different formats of publication and publication in different languages need different UBN, but these all UBNs will be provided at No additional cost. So if you publish a document in two languages and two formats e.g. print and online, you will be provided 4 UBNs at just US$ 100. If you publish the same document in pdf, HTML, JPEG, you will be provided extra UBNs at No additional cost. Demand for UBN can be sought at: ubnenquiry@gmail.com


Management of UBN
Allotment of UBN is done with a centralized system. There are no country wise agencies, to enhance the ease and user friendly approach. In case of any ambiguity, the decision of UABN shall be final and binding.

Cancellation of UBN
UBN assigned once, can not be cancelled.

Portability of UBN

Authors/ Publishers may sell/ resale unutilized UBN upon notifying UABNUBN can also be sold / purchased in a block. Unutilized UBN can also be sold within/ beyond the countries, different publishers/ authors and to a book in different languages.  If title of a book is changed in future, it needs to be assigned new UBNUBN can also be purchased in reserve for further use/ a book being planned to edit/ publish. UBN does not expire. UBN can also be demanded for a book, which is already having / not having an ISSN number.

Advance Directive for Health Care

Universal Book Number: --------------------?

By:


Date of Birth:


(Print Name)


(Month/Day/Year)

This advance directive for health care has four parts:

PART ONE—Health Care Agent.  This part allows you to choose someone to make health care decisions for you when you cannot (or do not want to) make health care decisions for yourself. The person you choose is called a health care agent. You may also have your health care agent make decisions for you after your death with respect to an autopsy, organ donation, body donation, and final disposition of your body. You should talk to your health care agent about this important role.

PART TWO—Treatment Preferences. This part allows you to state your treatment preferences if you have a terminal condition or if you are in a state of permanent unconsciousness. PART TWO will become effective only if you are unable to communicate your treatment preferences. Reasonable and appropriate efforts will be made to communicate with you about your treatment preferences before PART TWO becomes effective. You should talk to your family and others close to you about your treatment preferences.

PART THREE—Guardianship. This part allows you to nominate a person to be your guardian should one ever be needed.

PART FOUR—Effectiveness and Signatures. This part requires your signature and the signatures of two witnesses. You must complete PART FOUR if you have filled out any other part of this form.

You may fill out any or all of the first three parts listed above. You must fill out PART FOUR of this form in order for this form to be effective.

You should give a copy of this completed form to people who might need it, such as your health care agent, your family, and your physician. Keep a copy of this completed form at home in a place where it can easily be found if it is needed. Review this completed form periodically to make sure it still reflects your preferences. If your preferences change, complete a new advance directive for health care.

Using this form of advance directive for health care is completely optional. Other forms of advance directives for health care may be used in Georgia.

You may revoke this completed form at any time. This completed form will replace any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that you have completed before completing this form.




PART ONE—Health Care Agent

PART ONE will be effective even if PART TWO is not completed. A physician or health care provider who is directly involved in your health care may not serve as your health care agent. If you are married, a future divorce or annulment of your marriage will revoke the selection of your current spouse as your health care agent. If you are not married, a future marriage will revoke the selection of your health care agent unless the person you selected as your health care agent is your new spouse.


1.  Health Care Agent

I select the following person as my health care agent to make health care decisions for me:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

2.  Back-Up Health Care Agent

This section is optional. PART ONE will be effective even if this section is left blank.

If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable efforts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-up health care agent(s):

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)


3.  General Powers of Health Care Agent

My health care agent will make health care decisions for me when I am unable to communicate my health care decisions or I choose to have my health care agent communicate my health care decisions.

My health care agent will have the same authority to make any health care decision that I could make. My health care agent´s authority includes, for example, the power to:
·        Admit me to or discharge me from any hospital, skilled nursing facility, hospice, or other health care facility or service;
·        Request, consent to, withhold, or withdraw any type of health care; and
·        Contract for any health care facility or service for me, and to obligate me to pay for these services (and my health care agent will not be financially liable for any services or care contracted for me or on my behalf).

My health care agent will be my personal representative for all purposes of federal or state law related to privacy of medical records (including the Health Insurance Portability and Accountability Act of 1996) and will have the same access to my medical records that I have and can disclose the contents of my medical records to others for my ongoing health care.

My health care agent may accompany me in an ambulance or air ambulance if in the opinion of the ambulance personnel protocol permits a passenger and my health care agent may visit or consult with me in person while I am in a hospital, skilled nursing facility, hospice, or other health care facility or service if its protocol permits visitation.

My health care agent may present a copy of this advance directive for health care in lieu of the original and the copy will have the same meaning and effect as the original.

I understand that under law: Mention name of law
·        My health care agent may refuse to act as my health care agent;
·        A court can take away the powers of my health care agent if it finds that my health care agent is not acting properly; and
·        My health care agent does not have the power to make health care decisions for me regarding psychosurgery, sterilization, or treatment or involuntary hospitalization for mental or emotional illness, mental retardation, or addictive disease under Universal Book Number………………..?


4.  Guidance for Health Care Agent

When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.
5.  Powers of Health Care Agent after Death

(A)  AUTOPSY

My health care agent will have the power to authorize an autopsy of my body unless I have limited my health care agent´s power by initialing below.

                                  _________ (Initials)           My health care agent will not have the power to authorize an autopsy of my body (unless an autopsy is required by law).


(B)  ORGAN DONATION AND DONATION OF BODY

My health care agent will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Georgia Anatomical Gift Act, unless I have limited my health care agent´s power by initialing below.

Initial each statement that you want to apply.

                                  _________ (Initials)           My health care agent will not have the power to make a disposition of my body for use in a medical study program.

      _________ (Initials)     My health care agent will not have the power to donate any of my organs.


(C)  FINAL DISPOSITION OF BODY

My health care agent will have the power to make decisions about the final disposition of my body unless I have initialed below.

      _________ (Initials)     I want the following person to make decisions about the final disposition of my body:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

I wish for my body to be:

                                  _________ (Initials)           Buried

OR
      _________ (Initials)     Cremated



PART TWO—Treatment Preferences

PART TWO will be effective only if you are unable to communicate your treatment preferences after reasonable and appropriate efforts have been made to communicate with you about your treatment preferences. PART TWO will be effective even if PART ONE is not completed. If you have not selected a health care agent in PART ONE, or if your health care agent is not available, then PART TWO will provide your physician and other health care providers with your treatment preferences. If you have selected a health care agent in PART ONE, then your health care agent will have the authority to make all health care decisions for you regarding matters covered by PART TWO. Your health care agent will be guided by your treatment preferences and other factors described in Law.


6.  Conditions

PART TWO will be effective if I am in any of the following conditions:

Initial each condition in which you want PART TWO to be effective.

                                  _________ (Initials)           A terminal condition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time.

                                  _________ (Initials)           A state of permanent unconsciousness, which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment.

My condition will be determined in writing after personal examination by my attending physician and a second physician in accordance with currently accepted medical standards.


7.  Treatment Preferences

State your treatment preference by initialing (A), (B), or (C). If you choose (C), state your additional treatment preferences by initialing one or more of the statements following (C). You may provide additional instructions about your treatment preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state your specific preferences regarding pain relief in the next section.

If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences, then:

(A)                            _________ (Initials)           Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.
OR

(B)                            _________ (Initials)           Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.
OR

(C)                            _________ (Initials)           I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:

Initial each statement that you want to apply to option (C).

                                  _________ (Initials)           If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.

                                  _________ (Initials)           If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.

                                  _________ (Initials)           If I need assistance to breathe, I want to have a ventilator used.

                                  _________ (Initials)           If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.
8.  Additional Statements

This section is optional. PART TWO will be effective even if this section is left blank. This section allows you to state additional treatment preferences, to provide additional guidance to your health care agent (if you have selected a health care agent in PART ONE), or to provide information about your personal and religious values about your medical treatment. For example, you may want to state your treatment preferences regarding medications to fight infection, surgery, amputation, blood transfusion, or kidney dialysis. Understanding that you cannot foresee everything that could happen to you after you can no longer communicate your treatment preferences, you may want to provide guidance to your health care agent (if you have selected a health care agent in PART ONE) about following your treatment preferences. You may want to state your specific preferences regarding pain relief.






9.  In Case of Pregnancy

PART TWO will be effective even if this section is left blank.

I understand that under Georgia law, PART TWO generally will have no force and effect if I am pregnant unless the fetus is not viable and I indicate by initialing below that I want PART TWO to be carried out.

      _________ (Initials)     I want PART TWO to be carried out if my fetus is not viable.




PART THREE—Guardianship


10.  Guardianship

PART THREE is optional. This advance directive for health care will be effective even if PART THREE is left blank. If you wish to nominate a person to be your guardian in the event a court decides that a guardian should be appointed, complete PART THREE. A court will appoint a guardian for you if the court finds that you are not able to make significant responsible decisions for yourself regarding your personal support, safety, or welfare. A court will appoint the person nominated by you if the court finds that the appointment will serve your best interest and welfare. If you have selected a health care agent in PART ONE, you may (but are not required to) nominate the same person to be your guardian. If your health care agent and guardian are not the same person, your health care agent will have priority over your guardian in making your health care decisions, unless a court determines otherwise.

State your preference by initialing (A) or (B). Choose (A) only if you have also completed PART ONE.

(A)                            _________ (Initials)           I nominate the person serving as my health care agent under PART ONE to serve as my guardian.
OR

(B)                            _________ (Initials)           I nominate the following person to serve as my guardian:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

PART FOUR—Effectiveness and Signatures

This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions.

This form revokes any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date.

Unless I have initialed below and have provided alternative future dates or events, this advance directive for health care will become effective at the time I sign it and will remain effective until my death (and after my death to the extent authorized in Section (5) of PART ONE).

                                  _________ (Initials)           This advance directive for health care will become effective on or upon _____________________ and will terminate on or upon _____________________.


You must sign and date or acknowledge signing and dating this form in the presence of two witnesses.  Both witnesses must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be together or present with you when you sign this form.

A witness:
·        Cannot be a person who was selected to be your health care agent or back-up health care agent in PART ONE;
·        Cannot be a person who will knowingly inherit anything from you or otherwise knowingly gain a financial benefit from your death; or
·        Cannot be a person who is directly involved in your health care.

Only one of the witnesses may be an employee, agent, or medical staff member of the hospital, skilled nursing facility, hospice, or other health care facility in which you are receiving health care (but this witness cannot be directly involved in your health care).

By signing below, I state that I am emotionally and mentally capable of making this advance directive for health care and that I understand its purpose and effect.


________________________________________________________________                        __________________________
(Signature of Declarant)                                                                                        (Date)


The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my personal observation, the declarant appeared to be emotionally and mentally capable of making this advance directive for health care and signed this form willingly and voluntarily.


________________________________________________________________                        __________________________
 (Signature of First Witness)                                                                                  (Date)

Print Name:

Address:



________________________________________________________________                        __________________________
 (Signature of Second Witness)                                                                             (Date)

Print Name:

Address:




This form does not need to be notarized.Advance Directive for Health Care

Universal Book Number: --------------------?

By:


Date of Birth:


(Print Name)


(Month/Day/Year)

This advance directive for health care has four parts:

PART ONE—Health Care Agent.  This part allows you to choose someone to make health care decisions for you when you cannot (or do not want to) make health care decisions for yourself. The person you choose is called a health care agent. You may also have your health care agent make decisions for you after your death with respect to an autopsy, organ donation, body donation, and final disposition of your body. You should talk to your health care agent about this important role.

PART TWO—Treatment Preferences. This part allows you to state your treatment preferences if you have a terminal condition or if you are in a state of permanent unconsciousness. PART TWO will become effective only if you are unable to communicate your treatment preferences. Reasonable and appropriate efforts will be made to communicate with you about your treatment preferences before PART TWO becomes effective. You should talk to your family and others close to you about your treatment preferences.

PART THREE—Guardianship. This part allows you to nominate a person to be your guardian should one ever be needed.

PART FOUR—Effectiveness and Signatures. This part requires your signature and the signatures of two witnesses. You must complete PART FOUR if you have filled out any other part of this form.

You may fill out any or all of the first three parts listed above. You must fill out PART FOUR of this form in order for this form to be effective.

You should give a copy of this completed form to people who might need it, such as your health care agent, your family, and your physician. Keep a copy of this completed form at home in a place where it can easily be found if it is needed. Review this completed form periodically to make sure it still reflects your preferences. If your preferences change, complete a new advance directive for health care.

Using this form of advance directive for health care is completely optional. Other forms of advance directives for health care may be used in Georgia.

You may revoke this completed form at any time. This completed form will replace any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that you have completed before completing this form.




PART ONE—Health Care Agent

PART ONE will be effective even if PART TWO is not completed. A physician or health care provider who is directly involved in your health care may not serve as your health care agent. If you are married, a future divorce or annulment of your marriage will revoke the selection of your current spouse as your health care agent. If you are not married, a future marriage will revoke the selection of your health care agent unless the person you selected as your health care agent is your new spouse.


1.  Health Care Agent

I select the following person as my health care agent to make health care decisions for me:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

2.  Back-Up Health Care Agent

This section is optional. PART ONE will be effective even if this section is left blank.

If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable efforts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-up health care agent(s):

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)


3.  General Powers of Health Care Agent

My health care agent will make health care decisions for me when I am unable to communicate my health care decisions or I choose to have my health care agent communicate my health care decisions.

My health care agent will have the same authority to make any health care decision that I could make. My health care agent´s authority includes, for example, the power to:
·        Admit me to or discharge me from any hospital, skilled nursing facility, hospice, or other health care facility or service;
·        Request, consent to, withhold, or withdraw any type of health care; and
·        Contract for any health care facility or service for me, and to obligate me to pay for these services (and my health care agent will not be financially liable for any services or care contracted for me or on my behalf).

My health care agent will be my personal representative for all purposes of federal or state law related to privacy of medical records (including the Health Insurance Portability and Accountability Act of 1996) and will have the same access to my medical records that I have and can disclose the contents of my medical records to others for my ongoing health care.

My health care agent may accompany me in an ambulance or air ambulance if in the opinion of the ambulance personnel protocol permits a passenger and my health care agent may visit or consult with me in person while I am in a hospital, skilled nursing facility, hospice, or other health care facility or service if its protocol permits visitation.

My health care agent may present a copy of this advance directive for health care in lieu of the original and the copy will have the same meaning and effect as the original.

I understand that under law: Mention name of law
·        My health care agent may refuse to act as my health care agent;
·        A court can take away the powers of my health care agent if it finds that my health care agent is not acting properly; and
·        My health care agent does not have the power to make health care decisions for me regarding psychosurgery, sterilization, or treatment or involuntary hospitalization for mental or emotional illness, mental retardation, or addictive disease under Universal Book Number………………..?


4.  Guidance for Health Care Agent

When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.
5.  Powers of Health Care Agent after Death

(A)  AUTOPSY

My health care agent will have the power to authorize an autopsy of my body unless I have limited my health care agent´s power by initialing below.

                                  _________ (Initials)           My health care agent will not have the power to authorize an autopsy of my body (unless an autopsy is required by law).


(B)  ORGAN DONATION AND DONATION OF BODY

My health care agent will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Georgia Anatomical Gift Act, unless I have limited my health care agent´s power by initialing below.

Initial each statement that you want to apply.

                                  _________ (Initials)           My health care agent will not have the power to make a disposition of my body for use in a medical study program.

      _________ (Initials)     My health care agent will not have the power to donate any of my organs.


(C)  FINAL DISPOSITION OF BODY

My health care agent will have the power to make decisions about the final disposition of my body unless I have initialed below.

      _________ (Initials)     I want the following person to make decisions about the final disposition of my body:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

I wish for my body to be:

                                  _________ (Initials)           Buried

OR
      _________ (Initials)     Cremated



PART TWO—Treatment Preferences

PART TWO will be effective only if you are unable to communicate your treatment preferences after reasonable and appropriate efforts have been made to communicate with you about your treatment preferences. PART TWO will be effective even if PART ONE is not completed. If you have not selected a health care agent in PART ONE, or if your health care agent is not available, then PART TWO will provide your physician and other health care providers with your treatment preferences. If you have selected a health care agent in PART ONE, then your health care agent will have the authority to make all health care decisions for you regarding matters covered by PART TWO. Your health care agent will be guided by your treatment preferences and other factors described in Law.


6.  Conditions

PART TWO will be effective if I am in any of the following conditions:

Initial each condition in which you want PART TWO to be effective.

                                  _________ (Initials)           A terminal condition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time.

                                  _________ (Initials)           A state of permanent unconsciousness, which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment.

My condition will be determined in writing after personal examination by my attending physician and a second physician in accordance with currently accepted medical standards.


7.  Treatment Preferences

State your treatment preference by initialing (A), (B), or (C). If you choose (C), state your additional treatment preferences by initialing one or more of the statements following (C). You may provide additional instructions about your treatment preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state your specific preferences regarding pain relief in the next section.

If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences, then:

(A)                            _________ (Initials)           Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.
OR

(B)                            _________ (Initials)           Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.
OR

(C)                            _________ (Initials)           I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:

Initial each statement that you want to apply to option (C).

                                  _________ (Initials)           If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.

                                  _________ (Initials)           If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.

                                  _________ (Initials)           If I need assistance to breathe, I want to have a ventilator used.

                                  _________ (Initials)           If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.
8.  Additional Statements

This section is optional. PART TWO will be effective even if this section is left blank. This section allows you to state additional treatment preferences, to provide additional guidance to your health care agent (if you have selected a health care agent in PART ONE), or to provide information about your personal and religious values about your medical treatment. For example, you may want to state your treatment preferences regarding medications to fight infection, surgery, amputation, blood transfusion, or kidney dialysis. Understanding that you cannot foresee everything that could happen to you after you can no longer communicate your treatment preferences, you may want to provide guidance to your health care agent (if you have selected a health care agent in PART ONE) about following your treatment preferences. You may want to state your specific preferences regarding pain relief.






9.  In Case of Pregnancy

PART TWO will be effective even if this section is left blank.

I understand that under Georgia law, PART TWO generally will have no force and effect if I am pregnant unless the fetus is not viable and I indicate by initialing below that I want PART TWO to be carried out.

      _________ (Initials)     I want PART TWO to be carried out if my fetus is not viable.




PART THREE—Guardianship


10.  Guardianship

PART THREE is optional. This advance directive for health care will be effective even if PART THREE is left blank. If you wish to nominate a person to be your guardian in the event a court decides that a guardian should be appointed, complete PART THREE. A court will appoint a guardian for you if the court finds that you are not able to make significant responsible decisions for yourself regarding your personal support, safety, or welfare. A court will appoint the person nominated by you if the court finds that the appointment will serve your best interest and welfare. If you have selected a health care agent in PART ONE, you may (but are not required to) nominate the same person to be your guardian. If your health care agent and guardian are not the same person, your health care agent will have priority over your guardian in making your health care decisions, unless a court determines otherwise.

State your preference by initialing (A) or (B). Choose (A) only if you have also completed PART ONE.

(A)                            _________ (Initials)           I nominate the person serving as my health care agent under PART ONE to serve as my guardian.
OR

(B)                            _________ (Initials)           I nominate the following person to serve as my guardian:

Name:

Address:

Telephone Numbers:


(Home, Work, and Mobile)

PART FOUR—Effectiveness and Signatures

This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions.

This form revokes any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date.

Unless I have initialed below and have provided alternative future dates or events, this advance directive for health care will become effective at the time I sign it and will remain effective until my death (and after my death to the extent authorized in Section (5) of PART ONE).

                                  _________ (Initials)           This advance directive for health care will become effective on or upon _____________________ and will terminate on or upon _____________________.


You must sign and date or acknowledge signing and dating this form in the presence of two witnesses.  Both witnesses must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be together or present with you when you sign this form.

A witness:
·        Cannot be a person who was selected to be your health care agent or back-up health care agent in PART ONE;
·        Cannot be a person who will knowingly inherit anything from you or otherwise knowingly gain a financial benefit from your death; or
·        Cannot be a person who is directly involved in your health care.

Only one of the witnesses may be an employee, agent, or medical staff member of the hospital, skilled nursing facility, hospice, or other health care facility in which you are receiving health care (but this witness cannot be directly involved in your health care).

By signing below, I state that I am emotionally and mentally capable of making this advance directive for health care and that I understand its purpose and effect.


________________________________________________________________                        __________________________
(Signature of Declarant)                                                                                        (Date)


The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my personal observation, the declarant appeared to be emotionally and mentally capable of making this advance directive for health care and signed this form willingly and voluntarily.


________________________________________________________________                        __________________________
 (Signature of First Witness)                                                                                  (Date)

Print Name:

Address:



________________________________________________________________                        __________________________
 (Signature of Second Witness)                                                                             (Date)

Print Name:

Address:



This form does not need to be notarized.

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