Petition For Appointment Of A Temporary Medical Consent Guardian For A Proposed Medical Consent Ward {GPCSF 36}

GEORGIA PROBATE COURT STANDARD FORM Petition for the Appointment of a Temporary Medical Consent Guardian for a Proposed Medical Consent Ward INSTRUCTIONS I. Specific Instructions 1. This form is to be used in cases when, according to the provisions of O.C.G.A. §29-4-18, a medical procedure is necessary, the proposed ward is unable to consent, and no other person as provided in O.C.G.A. §31-9-2 is able or willing to make the medical decisions. The form must be completed so as to set forth facts which will establish probable cause to believe that the proposed medical consent ward lacks decision-making capacity and is in need of a temporary medical consent guardian, pursuant to O.C.G.A. §29-4-18, including but not limited to a. that the requested medical decision is necessary and why the decision is needed without undue delay; b. that the ward is unable to make or communicate such medical decision; c. the anticipated duration of the temporary medical consent guardianship; d. that no other person has the authority and/or willingness to make the medical decision; and e. whether a petition for the appointment of a guardian or conservator has been filed or will be filed as to this proposed ward. According to Probate Court Rule 5.6 (A), unless the court specifically assumes responsibility, it is the responsibility of the moving party to prepare the proper citation and deliver it properly so that it can be served according to law. The pages labeled "court" in the footnote are to be completed by the moving party, unless otherwise directed by the court. If probable cause is found by the court, a preliminary hearing shall be held 72 hours after the filing of the petition, notice of which shall be given to the proposed medical consent ward in accordance with O.C.G.A. §29-4-18(d) and, unless waived by the court, in accordance with O.C.G.A. §29-4-18(e). At the preliminary hearing the court may appoint a temporary medical consent guardian, set an evidentiary hearing to be conducted no later than four (4) days after the preliminary hearing, or dismiss the petition by issuing a court order. The forms herein allow the date for any evidentiary hearing to be determined and set in the order setting the preliminary hearing, but the decision to go forward with the evidentiary hearing would be made at the time of the preliminary hearing. If the date and time of the evidentiary hearing was not set until the preliminary hearing, a second notice shall be given to the proposed medical consent ward and may be given to any interested party according to O.C.G.A. §29-4-18(e) who had not been served previously with the order setting the preliminary hearing. Additional provisions are required to authorize withdrawal of life-sustaining procedures and must be specifically authorized by the court. 2. 3. 4. 5. 6. II. General Instructions: General instructions applicable to all Georgia probate court standard forms are available in each probate court. Effective 7/11 1 GPCSF 36 Petitioner American LegalNet, Inc. www.FormsWorkFlow.com GEORGIA PROBATE COURT STANDARD FORM PROBATE COURT OF STATE OF GEORGIA IN RE: ) ) ________________________________, ) PROPOSED MEDICAL CONSENT WARD ) ) ) COUNTY ESTATE NO. _______________________ PETITION FOR APPOINTMENT OF A TEMPORARY MEDICAL CONSENT GUARDIAN FOR A PROPOSED MEDICAL CONSENT WARD TO THE HONORABLE JUDGE OF THE PROBATE COURT: 1. Petitioner, ______________________________________________________________, is the (relationship)________________________________________________________ of the proposed ward, and is domiciled at (address of petitioner)___________________________________________________ County of ________________ , State of __________________, telephone number _________________. 2. The proposed ward is _____ years of age, was born (date of birth)______________________, is domiciled at (address) __________________________________________________________________, _____________County, State of_____________, and is presently located at_______________________, a (type of facility, if applicable) ___________________________ in ______________________ County and can be contacted at (telephone number) (initial if applicable) __________ It is anticipated that the proposed ward will be moved within the next 3 days to the following address: ____________________________________________, telephone number ______________________________ . 3. The proposed medical consent ward is in need of a temporary medical consent guardian by reason of the following incapacity: _____________________________________________________________ to the extent that the proposed medical consent ward lacks sufficient understanding or capacity to make significant responsible decisions regarding his or her medical treatment or lacks the ability to communicate such decisions by any means. The facts which support the claim of the need for a temporary medical consent guardian are as follows: NOTE: Pursuant to O.C.G.A. §29-4-18, the Court shall dismiss the petition if the petitioner does not allege sufficient facts to establish that the proposed medical consent ward is in need of a temporary Effective 7/11 2 GPCSF 36 Petitioner American LegalNet, Inc. www.FormsWorkFlow.com _. GEORGIA PROBATE COURT STANDARD FORM medical consent guardian as stated above. The petition cannot be granted unless sufficient facts are presented which support the need for the appointment of a temporary medical consent guardian. While a physician's affidavit is permissible, the petitioner MUST specifically allege sufficient facts to support the granting of this petition. _____________________________________________________________________________________ _____________________________________________________________________________________ The foreseeable duration of the proposed medical consent ward's incapacity will be: _________. 4. The following medical decisions are needed and must be made without undue delay: (NOTE: set forth the types of treatment and/or medical procedures for which consent is needed and state why the decision(s) must be made without undue delay, that is, why the procedures for the appointment of a non-emergency (permanent) guardian are inadequate to meet the needs of the circumstances): _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________