State Of Arizona Living Will (End Of Life Care) Page 5
Download a blank fillable State Of Arizona Living Will (End Of Life Care) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Of Arizona Living Will (End Of Life Care) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9STATE OF ARIZONA
DURABLE HEALTH CARE POWER OF ATTORNEY
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: (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:
Street Address:
City, State, Zip:
Home Telephone:
Work Telephone:
Cell Telephone:
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:
Street Address:
City, State, Zip:
Home Telephone:
Work Telephone:
Cell Telephone:
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal