State Of Arizona Living Will (End Of Life Care) Page 6
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9decisions 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 and an intensive
treatment program – called a “level one” behavioral health facility – using just
this form;
• 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 (want) an autopsy.
Upon my death I DO consent to (want) an 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
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