Arizona Durable Medical Power of Attorney Form

The Arizona Medical Power Of Attorney document is to legally allow an appointed person or sometimes called `Attorney In Fact` to make decisions regarding medical health care treatment on the patient`s behalf should they become incapacitated to a level where they are no longer able to make these decisions themselves. These conditions could include brain damage or coma for examples. The document requires at least or two witnesses, one of the witnesses may not be in any way a devicee or relative of the principal. The document is in accordance with statute § 13.52.010.

How to Write

Step 1

Step 1 – Download and carefully read all of the document before completing the blank fields by following the instructions written below.

Durable Health Care Power Of Attorney

1) Information About The Principal

  • Print name
  • Address
  • Age
  • Date of birth
  • Telephone number

2) Designation Of Agents

  • Print name of agent
  • Address
  • Telephone numbers Home/Work/Cell

If the principal wishes an auxiliary agent may also be nominated.  This is in case of an event due to which the primary agent is unable to carry out the agents duties.

4) Agent`s Authority

  • Option to enter the specific wishes of the principal to be carried out by the agent and giving authority to the agent regarding health care decisions that are NOT to be carried out should the principal be unable to do so themselves.

5) Autopsy

The user must check one of the relevant fields.

  • Upon death DO NOT consent to an autopsy.
  • Upon death DO consent to an autopsy.
  • The representative may give or refuse consent for an autopsy

End of life decisions.

  •  Initial selection `A`choice to prolong life or `B` choice not to prolong life.
  • If selecting section `B` then also initial either `B(i) permanent unconsciousness` or `B(ii)` terminal condition and/or `B(iii)` additional instructions.
  • Initial one of the following selections regarding artificial nutrition and hydration  `C (i), (ii), (iii), (iv) and/or (v) for other instructions`.
  • Agree to the statement provided in section `D` or give instructions regarding relief of pain.
  •  Give instructions for section `E` regarding consciousness during pregnancy.

(7) Other wishes

Enter details of principals other wishes regarding end of life decisions.

 

6) Anatomical Donation 

  • Check Box `A` if an anatomical gift is NOT to be given and NO authorization is to be given to the agent regarding organ donation.
  • Check box `B` to choose to give organs, tissues and other body parts.

B1a

  • Check box to give any needed body parts, organs and tissues.

B1b

  • Check box and Enter names of only the specific body parts, organs and tissues to be donated.

B2a

Check box for donated organs to be used for any legally authorized purpose.

B2b

  • Check box for donated organs to be used for transplant and therapeutic uses only

B2c

  • Check Boxes to describe the specific purposes designated for the anatomical gift upon death. 

B3a

  • Check box if the patient already has a donor card or has a designated organization for the donated organs.

B3b

  • Check box and name a specific organization to donate the organs to.

B3c

  • Check box to authorize agent to decide which organization to donate organs to.

7) Funeral And Burial Disposition

The patient must check the relevant box and enter the relevant details

  • Upon death the body is to be buried. (As opposed to cremated).
  • Upon death the body to be buried in a specific location.
  •  Upon death the body to be cremated.
  • Upon death the body to be cremated with the specific instructions regarding the ashes.
  • The agent will make all funeral and burial disposition decisions.

 

8) About A Living Will

The patient must check one of the boxes

  • `A` To show they have attached and signed a living will document to the Durable Health Care Power Of Attorney document.
  • `B` To show they have NOT attached and signed a living will document to the Durable Health Care Power Of Attorney document.

9) Prehospital Medical Care Directive or Do Not Resuscitate Directive

The patient must check one of the boxes

  • `A` To show they have signed a Prehospital Medical Care Directive or a Do Not Resuscitate Directive.
  • `B` To show they have NOT signed a Prehospital Medical Care Directive or Do Not Resuscitate Directive

10) HIPAA Waiver Of Confidentiality For The Agent or Representative 

The patient must initial to show they wish for discretion for their agent.

Signature Of Verification

The following blank fields must be completed with a printed name / a signature and date / address.

  • `A` Completed by the Patient.
  • `B` Completed by the agent in the event the principal is unable to carry out the signature.
  • `C` Completed by the witness or notary.

Notary Public

Details to be completed in the relevant fields by the notary of the witness did not sign the form.

  • County
  • Date
  • Name
  • Date commission expires