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Arizona Durable Medical Power of Attorney

In the state of Arizona, if an individual wants to legally grant another person with the ability to decide regarding future medical matters on their behalf, s/he only needs to complete this form and then have it notarized by a public attorney.

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STATE OF ARIZONA 	
DURABLE HEALTH CARE POWER OF ATTORNEY 	
Instructions and Form  	
 
GENERAL INSTRUCTIONS: Use this Durable Health Care Power of Attorney form if you want to select a 
person to make future health care de cisions for you so that if you become too ill or cann ot make those decisions 
for yourself the person you choose and trust can make m edical decisions for you. Talk to your family, friends, 
and others you trust about your choices. Also, it is a good  idea to talk with professionals such as your doctor, 
clergyperson and a lawyer before you sign this form.  
 
Be sure you understand the importance of this document. If you decide this is the form you want to use, 
complete the form. Do not sign this form until  your witness or a Notary Public is present to witness the 
signing. There are further instructions for  you about signing this form on page three.   
 
1. Information about me: (I am called the “Principal”)  
 
My Name:  ________________________    My Age:    ________________________ 
My Address:  ________________________    My Date of Birth: ________________________ 	
________________________    My Telephone:    ________________________ 	
  
2. Selection of my health care representative and alternate:  (Also called an "agent" or "surrogate")  
 
I choose the following person to act as my representative to make health care decisions for me: 
 
Name:     ________________________    Home Telephone: ________________________    
Street Address: ________________________      Work Telephone:  ________________________ 
City, State, Zip: ________________________    Cell Telephone:    ________________________ 
 
I choose the following person to act as an alternate repres entative to make health care decisions for me if my 
first representative is unavailable, unwilling, or unable to make decisions for me:  
 
Name:     ________________________    Home Telephone: ________________________    
Street Address: ________________________      Work Telephone:  ________________________ 
City, State, Zip: ________________________    Cell Telephone:    ________________________ 
 
3. What I AUTHORIZE if I am unable to  make medical care decisions for myself:   
 
I authorize my health care representative to make health care decisions for me when I cannot make or 
communicate my own health care decisions due to mental or physical illness,  injury, disability, or incapacity. I 
want my representative to make all such decisions for  me except those decisions that I have expressly stated in 
Part 4 below that I do not authorize him/her to make. If I am able to communicate in any manner, my 
representative should discuss my health care options  with me. My representative should explain to me any 
choices he or she made if I am able to  understand. This appointment is effective unless and until it is revoked by 
me or by an order of a court.  
 
The types of health care decisions I authorize to be  made on my behalf include but are not limited to the 
following:  
 	
¾   To consent or to refuse medical care, including  diagnostic, surgical, or therapeutic procedures;  
¾  To authorize the physicians, nurses, therapists, and  other health care providers of his/her choice to 
provide care for me, and to obligate my resources  or my estate to pay reasonable compensation for 
these services; 
¾   To approve or deny my ad mittance to health care institutions, nurs ing homes, assisted living facilities, or 
other facilities or programs. By signing this form I understand that I allow my representative to make 
decisions about my mental health care except  that generally speaking he or she cannot have me 
admitted to a structured treatment setting with 24 -hour-a-day supervision and an intensive treatment 
program – called a “level one” behavioral health facility – using just this form; 	
Developed by the Office of Arizona Attorney General                                                                                                Updated December 3, 2007 
TERRY GODDARD                                                                                      (All documents completed bef ore December 3, 2007 are still valid) 
www.azag.gov                                                                                    1                              DURABLE HEALT H CARE POWER OF ATTORNEY

DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d) 	
 	
¾  To have access to and control over my medical  records and to have the authority to discuss those 
records with health care providers. 	
 
4. DECISIONS I EXPRESSLY DO NOT AUTHORIZE my Representative to make for me:   
 
I do not want my representative to make the following health care decisions for me (describe or write in “not 
applicable”):  
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
 
5. My specific desires about autopsy: 
 
NOTE: Under Arizona law, an autopsy is not required unless the county medical examiner, the county attorney, or a superior 
court judge orders it to be performed. See the General Inform ation document for more information about this topic. Initial or 
put a check mark by one of the following choices.  
 	
_____ Upon my death I DO NOT consent to (want) an autopsy.    
_____ Upon my death I DO consent to (want) an autopsy.    
_____ My representative may give or refuse consent for an autopsy. 	
 
6. My specific desires about organ donation: (“anatomical gift”)  
 
NOTE: Under Arizona law, you may donate a ll or part of your body.  If you do not make a choice, your representative or 
family can make the decision when you die.  You may indicate  which organs or tissues you want to donate and where you 
want them donated. Initial or put a check mark by A or B below. If you select B, continue with your choices.  
 
_____ A. I DO NOT WANT to make an organ or tissue donation, and I do not want this donation                                
        authorized on my behalf by my representative or my family.  
_____  B. I DO WANT to make an organ or tissue donation when I die.  Here are my directions:  
 	
1. What organs/tissues I choose to donate:  (Select a or b below)  	
_____ a.  Any needed parts or organs.  	
     _____ b.  These parts or organs: 
  1.) _____________________________________________________ 
  2.) _____________________________________________________ 
  3.) _____________________________________________________ 
 
2. What purposes I donate organs/tissues for:  (Select a, b, or c below)  	
  _____ a. Any legally authorized purpose (trans plantation, therapy, medical and dental 
           evaluation and research, and/or advancement of medical and dental science). 
  _____ b. Transplant or therapeutic purposes only.  
  _____ c. Other: _________________________________________________ 
 	
3. What organization or person I want my parts or organs to go to:   	
_____ a. I have already signed a written agreement or donor card regarding organ and tissue 
        donation with the following individual or institution: (Name) ______________________ 
  _____________________________________________________________________ 
_____ b.  I would like my tissues or organs to go to the following individual or institution:  	
  (Name) ______________________________________________________________ 	
_____ c. I authorize my representative to make this decision.  	
Developed by the Office of Arizona Attorney General                                                                                                Updated December 3, 2007 
TERRY GODDARD                                                                                      (All documents completed bef ore December 3, 2007 are still valid) 
www.azag.gov                                                                                    2                              DURABLE HEALT H CARE POWER OF ATTORNEY

DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d) 	
 
7. Funeral and Burial Disposition: (Optional) 
 
My agent has authority to carry out all matters relating to my funeral and burial disposition wishes in accordance 
with this power of attorney, which is effect ive upon my death. My wishes are reflected below: 
 
Initial or put a check mark by those choices you wish to select. 	
_____ Upon my death, I direct my body to be  buried. (As opposed to cremated)    
_____ Upon my death, I direct my body to be buried in _______________________________________ 
__________________________________________________________________. (Optional directive)    
_____ Upon my death, I direct my body to be cremated.   
_____ Upon my death, I direct my body to be cremated with my ashes to be _____________________ 
__________________________________________________________________. (Optional directive)     
_____ My agent will make all funeral and burial di sposition decisions. (Optional directive) 	
 
8. About a Living Will:  
 
NOTE: If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will 
to this form. A Living Will form is available on the Attorney General (AG) web site. Init ial or put a check mark by 
box A or B.  
 
_____ A. I have SIGNED AND ATTACHED a completed Living Will in addition to this Durable Health Care 	
Power of Attorney to state decisions I have made about end of life health care if I am unable to 
communicate or make my own decisions at that time.  	
_____ B. I have NOT SIGNED a Living Will.  
 
9. About a Prehospital Medical Care Directive or Do Not Resuscitate Directive:   
 
NOTE: A form for the Prehospital Medical Care Directive or Do Not Resuscitate Directive is available on the AG 
Web site. Initial or put a check mark by box A or B.    
 
_____ A. I and my doctor or health care provider HAVE SIGNED  a Prehospital Medical Care Directive or Do Not 	
Resuscitate Directive on paper with ORANGE background in the event that 911 or Emergency Medical 
Technicians or hospital emergency personnel ar e called and my heart or breathing has stopped. 	
_____ B. I have NOT SIGNED a Prehospital Medical Care Di rective or Do Not Resuscitate Directive.  
 	
HIPPA WAIVER OF CONFIDENTIALITY FOR MY AGENT/REPRESENTATIVE 	
 
_____ (Initial) I intend for my agent to be treated as I would be with respect to my rights regarding the use and 
disclosure of my individually identifiable health information or other medical records.  This release authority 
applies to any information governed by the Health In surance Portability and Accountability Act of 1996 (aka 
HIPAA), 42 USC 1320d and  45 CFR 160-164.  
 	
SIGNATURE OR VERIFICATION 	
 
A.  I am signing this Durable Health Care  Power of Attorney as follows:  
 
My Signature: ____________________________________________  Date: ___________________________ 
 
B. I am physically unable to sign this document, so a witness is verifying my desires as follows:  
 
Witness Verification:  I believe that this Durable Health Care Power of Attorney accurately expresses the 
wishes communicated to me by the principal of this document.  He/she intends to adopt this Durable Health 
Care Power of Attorney at this time.  He/she is physica lly unable to sign or mark this document at this time, and 
I verify that he/she directly indicated to me that the  Durable Health Care Power of Attorney expresses his/her 
wishes and that he/she intends to adopt the Durable  Health Care Power of Attorney at this time. 
Developed by the Office of Arizona Attorney General                                                                                                Updated December 3, 2007 
TERRY GODDARD                                                                                      (All documents completed bef ore December 3, 2007 are still valid) 
www.azag.gov                                                                                    3                              DURABLE HEALT H CARE POWER OF ATTORNEY

DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d) 	
 
Witness Name (printed): _____________________________________________________________________ 
Signature: ______________________________________________  Date: ____________________________ 
 	
SIGNATURE OF WITNESS OR NOTARY PUBLIC: 	
 
NOTE: At least one adult witness OR a Notary Public must  witness the signing of this document and then sign 
it. The witness or Notary Public CANNOT be anyone who is : (a) under the age of 18; (b) related to you by blood, 
adoption, or marriage; (c) entitled to any part of your estate; (d) appointed as your representative; or (e) involved 
in providing your health care at the time this form is signed.  
 	
A. Witness: I certify that I witnessed the signing of this  document by the Principal. The person who signed 
this Durable Health Care Power of Attorney appear ed to be of sound mind and under no pressure to 
make specific choices or sign the document.  I  understand the requirements of being a witness and I 
confirm the following: 	
 	
¾   I am not currently designated to make medical decisions for this person.   
¾  I am not directly involved in adminis tering health care to this person. 
¾  I am not entitled to any portion of this person's  estate upon his or her death under a will or by 
operation of law.   
¾  I am not related to this person by blood, marriage or adoption.  	
 
Witness Name (printed): _____________________________________________________________________ 
Signature: ________________________________________________  Date: __________________________ 
Address: _________________________________________________________________________________ 
 
Notary Public (NOTE: If a witness signs your form, you DO NOT need a notary to sign):  
 	
STATE OF ARIZONA       ) ss  
COUNTY OF    ____________________)  	
 	
The undersigned, being a Notary Public certified in  Arizona, declares that the person making this 
Durable Health Care Power of Attorney has dated and signed or marked it in my presence and appears 
to me to be of sound mind and free from duress. I further declare I am not related to the person signing 
above by blood, marriage or adoption, or a person designated to make medical decisions on his/her 
behalf. I am not directly involved in providing health care to the person signing. I am not entitled to any 
part of his/her estate under a will now existing or  by operation of law. In the event the person 
acknowledging this Durable Health Care Power of A ttorney is physically unable to sign or mark this 
document, I verify that he/she directly indicated to me  that this Durable Health Care Power of Attorney 
expresses his/her wishes and that he/she intends to  adopt the Durable Health Care Power of Attorney 
at this time.   	
 
WITNESS MY HAND AND SEAL this  ___ day of ______________, 20___.  
Notary Public _____________________________________  My Commission Expires:  __________________  
 	
OPTIONAL:  	
STATEMENT THAT YOU HAVE DISCUSSED 	
YOUR HEALTH CARE CHOICES FOR THE FUTURE 	
WITH YOUR PHYSICIAN   	
 
NOTE: Before deciding what health care you want for yo urself, you may wish to ask your physician questions 
regarding treatment alternatives. This statement from your physician is not required by Arizona law. If you do 
speak with your physician, it is a good idea to have him or her complete this section. Ask your doctor to keep a 
copy of this form with your medical records.  
 
Developed by the Office of Arizona Attorney General                                                                                                Updated December 3, 2007 
TERRY GODDARD                                                                                      (All documents completed bef ore December 3, 2007 are still valid) 
www.azag.gov                                                                                    4                              DURABLE HEALT H CARE POWER OF ATTORNEY

DURABLE HEALTH CARE POWER OF ATTORNEY (Last Page) 	
 
On this date I reviewed this document with the Principal and discussed any questions regarding the probable 
medical consequences of the treatment choices provided above. I agree to comp ly with the provisions of this 
directive, and I will comply with the health care decisi ons made by the representative unless a decision violates 
my conscience. In such case I will promptly disclose  my unwillingness to comply and will transfer or try to 
transfer patient care to another  provider who is willing to act in accordan ce with the representative's direction.  
 
Doctor Name (printed): ______________________________________________________________________ 
Signature: ________________________________________________  Date: __________________________ 
Address: _________________________________________________________________________________ 
 
Developed by the Office of Arizona Attorney General                                                                                                Updated December 3, 2007 
TERRY GODDARD                                                                                      (All documents completed bef ore December 3, 2007 are still valid) 
www.azag.gov                                                                                    5                              DURABLE HEALT H CARE POWER OF ATTORNEY
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