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Office of the Attorney General of Arizona, Mark Brnovich Life Care Planning Packet: Prehospital Medical Care Directive Section 7: Page 1 of 1 Updated 06/16 PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE) (IMPORTANT —THIS DOCUMENT MUST BE ON PAPER WITH ORANGE BACKGROUND) 1. My Directive and My Signature: In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life sup port drugs and related emergency medical procedures. Patient Signature: Date: PROVIDE THE FOLLOWING INFORMATION : OR ATTACH RECENT PHOTOGRAPH HERE: 2. Information About My Doctor and Hospice (if I am in Hospice) : Physician: Telephone: Hospice Program, if applicable (name): PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE) (Last Page) 3. Signature of Doctor or Other Health Care Provider: I have explained this form and its consequences to the signer and obtained assurance that the signer understands that death may result from any refused care listed above. Signature of a Licensed Health Care Provider: Date: 4. Signature of Witness to My Directive : I was present when this form was signed (or marked). The patient then appeared to be of sound mind and free from duress. Signat ure: Date: GENERAL INFORMATION AND INSTRUCTIONS : A Prehospital Medica l Care Directive is a document signed by you and your doctor that informs emergency medical technicians (EMTs) or ho spital emergency personnel not to resuscitate you. Sometimes this is called a DNR – Do Not Resuscitate. If you have this form, EMTs and other emergency personnel will not use equipment, drugs, or devices to restart your heart or breathing, but they will no t withhold medical interventions that are necessary to provide comfort care or to alleviate pain. IMPORT ANT : Under Arizona law a Prehospital Medical Care Directive or DNR must be on letter sized paper or wallet sized paper on an orange background to be valid. You can either attach a picture to this form, or complete the personal information. You must also complete the form and sign it in front of a witness. Your health care provider and your witness must sign this form. NOTE: At least one adult witness OR a Notary Public must witness the signing of this document. 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 par t of your estate; (d) appointed as your representative; or (e) involved in providing your health care at the time this form is signed. My Date of Birth My Sex My Race My Eye Color My Hair ColorRelevant article from our knowledge database
The other type of HMO is known as a cost'' HMO. While HMOs are thought to be a medical care bargain, you need to consider joining one with caution. Most HMOs charge their very own monthly premium as well as a little copayment every time you use a service.
Providers still must get paid, even when budget was exceeded. You may use healthcare providers away from the plan and the bill is going to be sent to Medicare. You may want to speak to your doctor or attorney to be sure you have finished the living will in a manner your wishes will be understood.
You must purchase the plan from precisely the same company that gives your Select coverage. Some or each of the plans are provided in the majority of states. These plans and programs may help you pay costs.
Some plans provide benefits that Medicare doesn't provide, such as emergency care outside the usa. In case the plan does not provide prescription drug benefits, you can purchase another Part D prescription drug program. If your plan discontinues services, you'll need to locate a new plan in your town or return to original Medicare. 12 Advantage plans provide additional gap coverage.