MEDICAL POWER OF ATTORNEY

IMPORTANT INFORMATION

IT IS IMPORTANT THAT YOU REVIEW THE FOLLOWING INFORMATION BEFORE YOU

SIGN THIS DOCUMENT. READ THE INFORMATION CAREFULLY AND SEEK GUIDANCE
FROM A HEALTHCARE PROFESSIONAL OR ATTORNEY IF YOU DO NOT UNDERSTAND
ANY OF THE TERMS.

By signing this document, you are giving authority to the person you are designating as your Agent to
make medical decisions on your behalf. Medical decisions can include any medical service, treatment,
medical procedure, diagnosis or treat both mental and physical conditions. Your Agent will be able to
act with the same authority you would have if you were able to act for yourself and will have the
authority to consent and refuse to consent to medical treatment including decisions about
withdrawing or withholding life-sustaining treatment. It is, therefore, important that you know and
trust your agent and that your agent is aware of your preferences for health care treatment.

Even after you sign this document, you will still be able to make your health care decisions assuming
you are still considered mentally competent. Your agent cannot act on your behalf until your physician
has determined that you are no longer physically or mentally able to make medical decisions unless
otherwise stated in this document.

The person you choose as your agent must be at least eighteen years old and someone that you trust
with your health care. Your agent is not liable for any decisions they make on your behalf, as long as
those decisions were made in good faith. You should make sure that you have chosen an agent that
wants to take on the role of the agent. Discuss your medical preferences with your agent so they are
aware of your wishes. Review this document with your agent so they are aware of their role. You also
may choose up to two (2) Alternate Agents in case your main Agent is unavailable to act. Your
Alternate Agent(s) should also be over 18 and aware of your preferences.

You may revoke this document at any time while you are still competent to do so. You may revoke it by
telling your medical provider and your agent that you are revoking the document or you may provide
them a written revocation (Recommended). If you execute another power of attorney later, that will
have the effect of revoking this one.

In order for this document to be valid, it must be signed in the presence of a notary or two (2)
witnesses. If you choose to have two witnesses sign, they must be at least 18, competent and
independent and not your agent or related to your agent.

PART I. APPOINTMENT OF HEALTH CARE AGENT

I, Ricky Walker, of 2683 Charlestown Dr, Apt 33A, College Park, Georgia, 30337 (hereinafter known
as the “Principal”) hereby appoint, Queen Walker, of 2683 Charlestown Dr, Apt 33A, College Park,
Georgia, 30337 (hereinafter known as the “Agent”) as my Agent to make any and all medical decisions

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on my behalf, except to the extent that I limit in this document. My Agent can be reached at the
following contact information:

Home Phone: N/A Work Phone: N/A

Cell Phone: (404) 547-7789 E-Mail: misstooty31@icloud.com

APPOINTMENT OF ALTERNATE AGENT(S)

If my Agent appointed above is unable or unwilling to serve, there shall be no other individuals
authorized to make medical decisions on my behalf.

LIMITATIONS OF MY AGENT

Initial

_______ - AGENT'S AUTHORITY: shall not have any limitations to the medical decision making
powers they may make on my behalf. Therefore I acknowledge that the Agent shall have the right to
provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to
keep me alive.

_______ - I intend for my agent to be treated as I would with respect to my rights regarding the use and
disclosure of my individually identifiable health information or medical records. This release authority
applies to information governed by the Health Insurance Portability and Accountability Act (HIPAA) of
1996, 42 USC 1320d, 45 CFR 160-164.

DURATION

Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I
cannot revoke this document during the time I am considered incompetent to make my own decisions.

Initial

_______ - This document shall not have an end date and shall terminate upon revocation, a new
medical power of attorney, or my death.

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE

My Agent's authority becomes effective (Initial Below):

Initial

_______ - Immediately to make health care decisions on my behalf.

AGENT'S OBLIGATION

My Agent shall make health care decisions for me in accordance with this power of attorney for health
care, any instructions I give in Part II of this form, and my other wishes to the extent known to my
Agent. To the extent my wishes are unknown, my Agent shall make health care decisions for me in
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accordance with what my Agent determines to be in my best interest. In determining my best interest,
my Agent shall consider my personal values to the extent known to my Agent.

AGENT'S POST DEATH AUTHORITY

Initial

_______ - My Agent is authorized to make anatomical gifts, authorize an autopsy, and direct
disposition of my remains, except as I state here or in Part 3 of this form with no exceptions.

PRIOR MEDICAL POWER OF ATTORNEY

By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have
executed.
PART II. LIVING WILL
Initial

_______ - I, Ricky Walker, declare to include this Living Will as part of my Medical Power of Attorney
Form.

END-OF-LIFE DECISIONS

I direct that my health care providers and others involved in my care provide, withhold, or withdraw
treatment in accordance with the choice I have initialed below:

Initial

_______ - I choose to prolong life as long as possible within the limits of generally accepted health
care standards.

RELIEF FROM PAIN

Initial

_______ - In regards to pain, I direct that treatment for alleviation of pain or discomfort be provided at
all times, even if it hastens my death.

OTHER WISHES

Initial

_______ - I have no other medical requests.

PART III. DONATION OF ORGANS

Initial

_______ - I do not wish to donate any of my organs after my death.

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 PART IV. PRIMARY CARE PHYSICIAN
I, Ricky Walker, do not wish to enter my Primary Care Physician's information.

ORIGINAL AND COPIES OF THIS DOCUMENT

This original document and/or copies shall be kept at the following locations: Residence of Queen
Walker

GOVERNING LAW

This document shall be governed by the laws in the State of Georgia.

EXECUTION

You must initial, date, and sign this power of attorney before two (2) witnesses not related by blood or
marriage.

Principal’s Signature _____________________

Ricky Walker

Agent’s Signature _____________________

Queen Walker

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WITNESS STATEMENT AND ACKNOWLEDGMENT

I am not the person appointed as agent or successor agent in this medical power of attorney. I am not
related to Ricky Walker by blood or marriage. I am not entitled to any portion of the Ricky Walker's
estate, nor do I have any claim against their estate. I am not the attending physician of Ricky Walker or
an employee of the attending physician. I am not involved in providing direct patient care to Ricky
Walker and not an officer, director, partner, or business office employee of the health care facility or of
any parent organization of the healthcare facility.

SIGNATURE OF THE FIRST WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

SIGNATURE OF THE SECOND WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

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