State Of Arizona Durable Health Care Power Of Attorney Page 5
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5Notary Public (NOTE: If a witness signs your form, you DO NOT need a notary to sign):
STATE OF ARIZONA
) ss
COUNTY OF
)
The undersigned, being a Notary Public certified in Arizona, declares that the person making
this
Durable
Health Care Power of Attorney has dated and signed or marked it in my presence and appears to me to be of sound
mind and free from duress. I further declare I am not related to the person signing above by blood, marriage or
adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in providing
health care to the person signing. I am not entitled to any part of his/her estate under a will now existing or by
operation of law. In the event the person acknowledging this Durable Health Care Power of Attorney is physically
unable to sign or mark this document, I verify that he/she directly indicated to me that this 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 MY HAND AND SEAL this
day of
, 20
Notary Public
My Commission Expires:
OPTIONAL:
STATEMENT THAT YOU HAVE DISCUSSED YOUR
HEALTH CARE CHOICES FOR THE FUTURE WITHYOUR
PHYSICIAN
NOTE: Before deciding what health care you want for yourself, you may wish to ask your physician questions
regarding treatment alternatives. This statement from your physician is not required by Arizona law. If you do speak
with your physician, it is a good idea to have him or her complete this section. Ask your doctor to keep a copy of this
form with your medical records.
On this date I reviewed this document with the Principal and discussed any questions regarding the probable medical
consequences of the treatment choices provided above. I agree to comply with the provisions of this directive, and I
will comply with the health care decisions made by the representative unless a decision violates my conscience. In
such case I will promptly disclose my unwillingness to comply and will transfer or try to transfer patient care to another
provider who is willing to act in accordance with the representative's direction.
Doctor Name (printed):
_
Signature:
Date:
_
Address:
_
_
Office of the Attorney General of Arizona, Mark Brnovich
Sec. 3: Page 5 of 5
Updated 06/16
Life Care Planning Packet: Durable Health Care Power of Attorney
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