Arizona Mental Health Care Power of Attorney

MENTAL HEALTH CARE POWER OF ATTORNEY

(Arizona Revised Statutes §§ 36-3281 and 36-3282)

A person may use any writing that meets the requirements of sections 36-3281 and 36-3282 to create a mental health care power of attorney. The following form is offered as a sample only and does not prevent a person from using other language or another form.

GENERAL INSTRUCTIONS: Use this form if you want to appoint a person, also referred to as your agent, to make future mental health care decisions for you if you become incapable of making those decisions for yourself. The decision about whether you are incapable can only be made by a specialist in neurology or an Arizona licensed psychiatrist or psychologist who will evaluate whether you can give informed consent.

If you fill out this form, do not sign until your witness or a notary public is present to watch you sign it. At least one adult witness OR a notary public must witness you signing this document. Do not have the document signed by both a witness and a notary. Pick one.

A notary or witness shall not be a person designated to make medical decisions on your behalf or a professional care provider directly involved with the provision of care to you at the time this form is executed. If only one witness signs, that witness shall not be related to you by blood, marriage, or adoption, and shall not be entitled to any part of your estate by will or by operation of law at the time this power of attorney is executed.

My information (I am the Principal)

Name: ________________________________________

Date of Birth: ________________________

Address: ________________________________________________

Phone: ____________________________

Email: ____________________________________

Selection of my mental health care agent and alternate

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

Name: ________________________________________

Address: ________________________________________________

Home Phone: ________________________

Work Phone: ________________________

Cell Phone: ________________________

I choose the following person to act as an alternate to make mental health care decisions for me if my first agent is unavailable, unwilling, or unable to make decisions for me:

Name: ________________________________________

Address: ________________________________________________

Home Phone: ________________________

Work Phone: ________________________

Cell Phone: ________________________

Mental health treatments I AUTHORIZE

Here are the mental health treatments I authorize my agent to make for me if I become incapable of making my own mental health care decisions due to mental or physical illness, injury, disability, or incapacity. This appointment is effective unless and until it is revoked by me or by an order of a court. My agent is authorized to do the following which I have initialed:

(___) To receive medical records and information regarding my mental health treatment and to receive, review, and consent to disclosure of any of my medical records related to that treatment.

(___) To consent to the administration of any medications recommended by my treating physician.

(___) To admit me to an inpatient or partial psychiatric hospitalization program. (This authority must be separately initialed under A.R.S. § 36-3282(B).)

Other (optional):

________________________________________________________________________

________________________________________________________________________

Mental health treatments I expressly DO NOT AUTHORIZE

(Explain or write in "None")

________________________________________________________________________

________________________________________________________________________

Revocability

This mental health care power of attorney or any portion of it may not be revoked and any designated agent may not be disqualified by me during times that I am found to be unable to give informed consent. However, at all other times I retain the right to revoke all or any portion of this mental health care power of attorney or to disqualify any agent designated by me in this document.

HIPAA waiver of confidentiality for my agent

(___) I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release of authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. § 1320d and 45 C.F.R. parts 160-164.

My signature verification

__________________________________________

Signature of Principal

Date: ____________________

If you are unable to physically sign this document, your witness or notary may sign and initial for you after verifying that this document expresses your wishes and that you intend to adopt it at this time.

(OR)

Signature of Witness

I was present when this form was signed (or marked). The principal appeared to be of sound mind and was not forced to sign this form. I affirm that I meet the requirements to be a witness as indicated above.

__________________________________________

Signature of Witness

Printed Name: ____________________________________

Address: ________________________________________________

Date: ____________________

(OR)

Notary acknowledgment

If a witness signs your form, you should not have a notary sign.

STATE OF ARIZONA

COUNTY OF ______________________

Subscribed and sworn (or affirmed) before me this ________ day of ______________, 20______.

Principal's Name: ____________________________________

__________________________________________

Notary Public Signature

My Commission Expires: ____________________