State Of Arizona Durable Health Care Power Of Attorney Page 2
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5representative 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. I further authorize my representative to have all access to and copies of my “personal protected health
care information and medical records”. 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:
To consent or to refuse medical care, including diagnostic, surgical, or therapeutic procedures;
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;
To approve or deny my admittance to health care institutions, nursing 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 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 grant of authority;
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 Information 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 a voluntary autopsy.
Upon my death I DO consent to a voluntary 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 all 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:
Office of the Attorney General of Arizona, Mark Brnovich
Sec. 3: Page 2 of 5
Updated 06/16
Life Care Planning Packet: Durable Health Care Power of Attorney
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