This form lets doctors, hospitals and insurers share your medical information with a family member, agent, attorney or anyone else you choose. It is often signed alongside a power of attorney or advance directive so your agent can get records quickly. Many providers, insurers and attorneys prefer a notarized authorization because it proves the signature is yours. This form lets doctors, hospitals and insurers share your medical information with a family member, agent, attorney or anyone else you choose.
Georgia residents and families reviewing hipaa authorization.
What you'll need
Read the packet’s instructions before completing its fields.
Follow the packet’s signing, witness and identification instructions.
How to complete it
Patient information (Section 1) Enter your full legal name and date of birth exactly as on your medical records.
Who discloses and who receives (Sections 2–3) Choose any provider or list specific ones, then name the person or organization that may receive the records.
What information (Section 4) Check all records or limit by date or type. Mental health, substance use, HIV and genetic information are released only if you initial them in ink.
Purpose and expiration (Sections 5–6) Check the purpose and enter an end date or event, such as “conclusion of my claim.”
Sign before a notary Do not sign ahead of time. Bring a current government-issued photo ID. A personal representative signing for the patient should bring proof of authority.
This is Georgia’s official form for naming a health care agent and writing down your treatment wishes. It replaces the old Georgia living will and durable power of attorney for health care. It does not cover finances — for that, use a Georgia Statutory Form Power of Attorney. You may fill out any of Parts One to Three, but you must complete Part Four.
This notarized affidavit lets you choose who will make your funeral, burial or cremation decisions, and record your wishes. Without one, Georgia law gives that right to family in a fixed order, starting with a spouse, which can lead to disputes. A health care agent named in your Georgia Advance Directive still comes first, so make sure the two documents agree.
Use this form to cancel all or part of a Georgia Advance Directive for Health Care, or an older Georgia living will or durable power of attorney for health care. A signed, notarized revocation is clear written proof for hospitals, doctors and your former agent. If you want new instructions, sign a new Georgia Advance Directive for Health Care, which automatically replaces earlier ones.
These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.