Durable Health Care Power Of Attorney printable pdf download

STATE OF ARIZONA

DURABLE HEALTH CARE POWER OF ATTORNEY

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.

1. Information about me: (I am called the “Principal”)

My Name:

My Age: ________________________

My Address:

My Date of Birth: _________________

My Telephone: ___________________

2. Selection of my health care representative and alternate: (Also called an "agent" or "surrogate")

I choose the following person to act as my representative to make health care decisions for me:

Name:

Home Phone: ____________________

Street Address:

Work Phone: _____________________

City, State, Zip:

Cell Phone: ______________________

I choose the following person to act as an alternate representative to make health care decisions for me if

my first representative is unavailable, unwilling, or unable to make decisions for me:

Name:

Home Phone: ____________________

Street Address:

Work Phone: _____________________

City, State, Zip:

Cell Phone: ______________________

3. What 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 representative 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. 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 generally speaking he

or she cannot have me admitted to a structured treatment setting with 24-hour-a-day supervision

America Living Will Registry, LLC, 2814 Beach Boulevard South, St. Petersburg, FL 33707

1-866-305-ALWR

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Durable Health Care Power Of Attorney

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