Advance Directives

2023. Reproduction and distribution by an organization or organized group without the written

permission of the National Hospice and Palliative Care Organization is expressly forbidden.

GEORGIA

Advance Directive

Planning for Important Healthcare Decisions

Courtesy of CaringInfo

www.caringinfo.org

800-658-8898

CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is a

national consumer engagement initiative to improve care and the experience of caregiving

during serious illness and at the end of life. As part of that effort, CaringInfo provides detailed

guidance for completing advance directive forms in all 50 states, the District of Columbia, and

Puerto Rico.

This package includes:

• Instructions for preparing your advance directive. Please read all the instructions.

• Your state-specific advance directive forms, which are the pages with the gray

instruction bar on the left side.

BEFORE YOU BEGIN

Check to be sure that you have the materials for each state in which you may receive

healthcare. Because documents are state-specific, having a state-specific document for each

state where you may spend significant time can be beneficial. A new advance directive is not

necessary for ordinary travel into other states. The advance directives in this package will be

legally binding only if the person completing them is a competent adult who is 18 years of age

or older, or an emancipated minor.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will

have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you

through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure the

person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy, scan, or take a photo of the form and

give it to the person you have appointed to make decisions on your behalf, your family,

friends, healthcare providers, and/or faith leaders so that the form is available in the event

of an emergency.

5. You may also want to save a copy of your form in your electronic healthcare record, or an

online personal health records application, program, or service that allows you to share your

medical documents with your physicians, family, and others who you want to take an active

role in your advance care planning.

INTRODUCTION TO YOUR GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

This packet contains the Georgia Advance Directive for Health Care, which protects your

right to refuse medical treatment that you do not want or to request treatment you do want, in

the event you lose the ability to make decisions yourself.

Part One: Health Care Agent. This allows you to choose someone to make health care

decisions for you if you cannot (or do not want to) make health care decisions for yourself. 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.

Part Two: Treatment Preferences. This part allows you to state your treatment preferences

if you are (1) unable to communicate your treatment preferences, and (2) your physician and

one other physician determine that you either have a terminal condition or are in a state of

permanent unconsciousness. If you also have a health care agent, then your agent is authorized

to make all decisions discussed in Part Two, but will be guided by your written Treatment

Preferences as well as any other factors you may have listed in section 4 of Part One.

Part Three: Guardianship. This part allows you to nominate a person to be your guardian

should one ever be needed.

Part Four: Signatures. You may fill out any or all of the first three parts. You must fill out

Part Four.

How do I make my Georgia Advance Directive for Health Care legal?

The law requires that you sign your document, or another person signs it in your presence and

at your express direction, in the presence of two witnesses who must be at least 18 years of

age and of sound mind.

Your witnesses cannot be your health care agent, someone who will knowingly inherit anything

from you or otherwise gain a financial benefit from your death, or someone who is directly

involved in your healthcare.

Only one witness can be an employee, agent, or medical staff member of the facility in which

you are receiving healthcare.

Note: You do not need to notarize your Georgia Advance Directive for Health Care.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your healthcare if you become

unable to make those decisions yourself. Your agent may be a family member or a close friend

whom you trust to make serious decisions. The person you name as your agent should clearly

understand your wishes and be willing to accept the responsibility of making healthcare

decisions for you.

No physician or health care provider may act as your health care agent if he or she is directly

involved in your health care.

You can appoint a second and third person as your alternate agents. An alternate agent will

step in if the person(s) you name as agent is/are unable, unwilling, or unavailable to act for

you.

Should I add personal instructions to my advance directive?

Yes! One of the most important reasons to execute an advance directive is to have your voice

heard. When you name an agent and clearly communicate to them what you want and don’t

want, they are in the strongest position to advocate for you. Because the future is

unpredictable, be careful that you do not unintentionally restrict your agent’s power to act in

your best interest. Be especially careful with the words “always” and “never.” In any event, be

sure to talk with your agent and others about your future healthcare and describe what you

consider to be an acceptable “quality of life.”

When does my agent’s authority become effective?

Your health care agent’s power becomes effective when your doctor determines that you are no

longer able to make or communicate your health care decisions or when you decide to have your

health care agent make decisions for you.

You retain the primary authority for your healthcare decisions as long as you are able to make

your wishes known.

Agent Limitations

Your agent will be bound by the current laws of

Georgia as they regard pregnancy and

termination of pregnancies.

What if I change my mind?

You may revoke your Georgia advance directive for health care at any time, regardless of your

mental or physical condition, by:

• obliterating, burning, tearing, or otherwise destroying your document,

• signing and dating a written revocation or directing another person to do so (if you are

receiving healthcare in a healthcare facility, the revocation must be communicated to

your attending physician), or

• orally revoking your document in the presence of a witness, at least 18 years of age,

who must sign and date a written confirmation of your revocation within 30 days (if you

are receiving health care in a health care facility, the revocation must be communicated

to your attending physician).

• by completing a new advance directive for health care. A new advance directive will

revoke an older advance directive to the extent that they are inconsistent with each

other.

If you get married after completing your advance directive for health care and you have not

named your spouse as your health care agent, your marriage automatically revokes the power

of your health care agent. If you have appointed your spouse as your health care agent and you

divorce or the marriage is annulled, your health care agent’s power is automatically revoked.

You can, however, specify that you do not want these changes to occur in section 8 in PART

TWO of your advance directive for health care.

Mental Health Issues

These forms do not

expressly

address mental illness, although you can state your wishes and

grant authority to your agent regarding mental health issues. The National Resource Center on

Psychiatric Advance Directives maintains a website (https://nrc-pad.org/) with links to each

state’s psychiatric advance directive forms. If you would like to make more detailed advance

care plans regarding mental illness, you could talk to your physician and an attorney about a

durable power of attorney tailored to your needs.

What other important facts should I know?

If you are a woman and would like your treatment preferences regarding withholding or

withdrawal of life-sustaining procedures, nourishment, or hydration to be honored even if you are

pregnant, you must initial the statement in section 9 in PART TWO of the advance directive for health

care form. State law requires that, before honoring a pregnant patient’s Treatment Preferences,

the attending physician must first determine whether the fetus is viable. If the fetus is viable, your

treatment preferences will not be honored, even if you initial section 9.

Part III of your advance directive for health care provides space where you can nominate

someone to serve as your guardian if there should come a time when you need a court-

appointed guardian. Unless a court specifies otherwise, your guardian has no power to make

any personal or health care decisions granted to your agent under your advance directive for

health care.

Be aware that your advance directive will not be effective in the event of a medical emergency,

except to identify your agent. Ambulance and hospital emergency department personnel are

required to provide cardiopulmonary resuscitation (CPR) unless you have a separate physician’s

order, which are typically called “prehospital medical care directives” or “do not resuscitate

orders.” DNR forms may be obtained from your state health department or department of aging

(https://www.hhs.gov/aging/state-resources/index.html). Another form of orders regarding CPR

and other treatments are state-specific POLST (portable orders for life sustaining treatment)

(https://polst.org/form-patients/). Both a POLST and a DNR form MUST be signed by a

healthcare provider and MUST be presented to the emergency responders when they arrive.

These directives instruct ambulance and hospital emergency personnel not to attempt CPR (or

to stop it if it has begun) if your heart or breathing should stop.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 1 OF 12

By:

(Print Name)

Date of Birth:

(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.

Hospice and

Palliative Care

Organization.

2023 Revised.

INTRODUCTION

PRINT YOUR NAME

AND BIRTH DATE

INSTRUCTIONS

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 2 OF 12

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.

Once completed, this 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.

INTRODUCTION

CONTINUED

INSTRUCTIONS

Hospice and

Palliative Care

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2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 3 OF 12

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. Unless you specify otherwise in section 8 of PART TWO,

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. Unless you

specify otherwise in section 8 of PART TWO, 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)

INSTRUCTIONS

PRINT THE NAME

AND ADDRESS OF

YOUR HEALTH CARE

AGENT

PRINT NAMES,

ADDRESSES, AND

TELEPHONE

NUMBERS OF

YOUR ALTERNATE

HEALTH CARE

AGENTS

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GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 4 OF 12

(3) GENERAL POWERS OF HEALTH CARE AGENT

My health care agent will make health care decisions for me when I am unable to

make my health care decisions or I choose to have my health care agent make

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 Georgia 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.

(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.

INSTRUCTIONS

DESCRIPTION OF

POWERS OF

HEALTH CARE

AGENT

Hospice and

Palliative Care

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2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 5 OF 12

(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.

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

(Initials) Cremated

INSTRUCTIONS

INITIAL IF YOU DO

NOT WANT YOUR

HEALTH CARE

AGENT TO HAVE

POWER TO

AUTHORIZE AN

AUTOPSY

INITIAL

STATEMENTS THAT

YOU WANT TO

APPLY, IF ANY

INITIAL HERE IF

YOU WANT

SOMEONE OTHER

THAN YOUR

HEALTH CARE

AGENT TO MAKE

FINAL DISPOSITION

DECISIONS

INITIAL THE ONE

STATEMENT THAT

REFLECTS YOUR

WISH

Hospice and

Palliative Care

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Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 6 OF 12

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 Section (4) of PART ONE.]

(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 certified in writing after personal examination by my

attending physician and a second physician in accordance with currently

accepted medical standards.

INSTRUCTIONS

INITIAL THE

STATEMENTS THAT

REFLECT YOUR

WISH

YOU MAY INITIAL

BOTH STATEMENTS

Hospice and

Palliative Care

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2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 7 OF 12

(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, regardless of which choice you make, 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.

(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.

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.

INSTRUCTIONS

INITIAL ONE

STATEMENT THAT

REFLECTS YOUR

WISH

INITIAL ONLY ONE

(A, B, OR C)

IF YOU INITIAL (C),

INITIAL EACH

STATEMENT THAT

YOU WANT TO

APPLY

Hospice and

Palliative Care

Organization.

2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 8 OF 12

(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.]

INSTRUCTIONS

OPTIONAL SECTION

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

Hospice and

Palliative Care

Organization. 2023

Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 9 OF 12

(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.

INSTRUCTIONS

INITIAL HERE IF

YOU WANT PART

TWO TO BE

CARRIED OUT IF

YOU ARE PREGNANT

AND YOUR FETUS IS

NOT VIABLE

Hospice and

Palliative Care

Organization.

2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 10 OF 12

PART THREE: GUARDIANSHIP

(10) GUARDIANSHIP

[P AR T THR EE 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.

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

guardian:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

INSTRUCTIONS

INITIAL YOUR

PREFERENCE

REGARDING

NOMINATION OF

YOUR GUARDIAN,

IN THE EVENT YOU

NEED TO HAVE ONE

APPOINTED BY A

COURT

Hospice and

Palliative Care

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2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 11 OF 12

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;

•

A person who will knowingly inherit anything from you or otherwise

knowingly gain a financial benefit from your death; or

•

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)

INSTRUCTIONS

INITIAL HERE IF

YOU WANT TO

LIMIT WHEN THIS

ADVANCE

DIRECTIVE IS

EFFECTIVE

SIGN AND DATE

Hospice and

Palliative Care

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2023 Revised.

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE - PAGE 12 OF 12

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 witness) (Date)

Print Name:

Address:

(Signature of witness) (Date)

Print Name:

Address:

[This form does not need to be notarized.]

Courtesy of CaringInfo

www.caringinfo.org

INSTRUCTIONS

HAVE YOUR

WITNESSES SIGN,

DATE AND PRINT

THEIR ADDRESSES

HERE

Hospice and

Palliative Care

Organization.

2023 Revised.