State Of Arizona Durable Health Care Power Of Attorney
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5OFFICE OF THE ARIZONA ATTORNEY GENERAL
Mark Brnovich
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 decisions for you so that if you become too ill or cannot make those decisions for yourself the
person you choose and trust can make medical 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 (the Principal):
My Name:
My Age:
_
My Address:
_
My Date of Birth:
_
My Telephone:
_
2. Selection of my health care representative and alternate (“agent” or “surrogate”)
I choose the following person to act as my representative to make health care decisions for me:
Name:
Home Phone:
Address:
Work Phone:
Cell Phone:
I choose the following person to act as an alternate representative to make health care decisions on my behalf if the
first representative is unavailable, unwilling, or unable to make decisions for me:
Name:
Home Phone:
Address:
Work Phone:
Cell Phone:
3. 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
Office of the Attorney General of Arizona, Mark Brnovich
Sec. 3: Page 1 of 5
Updated 06/16
Life Care Planning Packet: Durable Health Care Power of Attorney
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