State Of Arizona Durable Health Care Power Of Attorney Page 4
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59. 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 a
Do Not Resuscitate Directive on Paper with ORANGE background in the event that 911 of Emergency
Medical Technicians or hospital emergency personnel are called and my heart or breathing has stopped.
B. I have NOT SIGNED a Prehospital Medical Care Directive or Do Not Resuscitate Directive.
10. HIPAA WAIVER OF CONFIDENTIALITY FOR MYAGENT/REPRESENTATIVE
(Initial) I intend for my agent to be treated as I would with respect to my rights regarding the use and disclosure
of my individually identifiable health information or medical records. This release authority applies to information
governed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 42 USC 1320d, 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 physically 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.
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 appeared 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:
I am not currently designated to make medical decisions for this person.
I am not directly involved in administering health care to this person.
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.
I am not related to this person by blood, marriage or adoption.
Witness Name (printed):
Signature:
Date:
_
Address:
Office of the Attorney General of Arizona, Mark Brnovich
Sec. 3: Page 4 of 5
Updated 06/16
Life Care Planning Packet: Durable Health Care Power of Attorney
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