Arizona Health Care Power of Attorney

HEALTH CARE POWER OF ATTORNEY (Arizona Revised Statute 36-3224)

Any writing that meets the requirements of section 36-3221 may be used to create a 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:

1. Health Care Power of Attorney

I, , as principal, designate as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and personal representatives as if I were alive, competent and acting for myself.

If my agent is unwilling or unable to serve or continue to serve, I hereby appoint as my agent.

I have I have not completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. My agent is directed to implement those choices I have initialed in the living will.

I have I have not completed a pre-hospital medical care directive pursuant to Section 36-3251, Arizona Revised Statutes.

This health care directive is made under section 36-3221, Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation.

__________ Signature of Principal Date

Principal’s Address:

2. Autopsy (under Arizona law an autopsy may be required)

If you wish to do so, reflect your desires below:

1. I do not consent to an autopsy. 2. I consent to an autopsy. 3. My agent may give consent to or refuse an autopsy.

3. Organ Donation (Optional)

(Under Arizona law, you may make a gift of all or part of your body to a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental SIGN

evaluation or research or for the advancement of medical or dental science. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself or state that you do not want to make a gift. If you do not complete this section, your agent will have the authority to make a gift of a part of your body pursuant to law. Note: The donation elections you make in this health care power of attorney survive your death.)

If any of the statements below reflects your desire, initial on the line next to that statement. You do not have to initial any of the statements.

If you do not check any of the statements, your agent and your family will have the authority to make a gift of all or part of your body under Arizona law.

I do not want to make an organ or tissue donation and I do not want my agent or family to do so.

I have already signed a written agreement or donor card regarding organ and tissue donation with the following individual or institution:

_______ Pursuant to Arizona law, I hereby give, effective on my death: [ ] Any needed organ or parts. [ ] The following part or organs listed:

________________________

________________________

for (check one): [ ] Any legally authorized purpose. [ ] Transplant or therapeutic purposes only.

4. Physician Affidavit (optional)

(Before initialing any choices above you may wish to ask questions of your physician regarding a particular treatment alternative. If you do speak with your physician it is a good idea to ask your physician to complete this affidavit and keep a copy for his file.)

I, Dr. have reviewed this guidance document and have discussed with [name of patient] any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with the principal occurred on [date].

I have agreed to comply with the provisions of this directive.

Signature of Physician

5. Living Will (Optional) The principal may separately execute a living will if so desired.

SIGN

(Note: This document may be notarized instead of being witnessed.)

STATEMENT OF WITNESSES

In accordance with the witnessing requirements under section 36-3221, Arizona Revised Statutes, we, the undersigned witnesses, affirm under penalty of perjury that we are at least 18 years of age and were present when the principal named in this health care power of attorney dated and signed or marked this document, and that the principal appeared to be of sound mind and free from duress at the time of execution of this health care power of attorney. We further affirm that we are not: (1) designated to make medical decisions on the principal's behalf under this or any other document or health care power of attorney; (2) directly involved with the provision of health care to the principal at the time of execution of this health care power of attorney; (3) related to the principal by blood, marriage or adoption; and (4) entitled to any part of the principal's estate by will or by operation of law at the time that the power of attorney is executed.

Witness #1:

_______________

__________ Printed Name Signature Date

Witness’s Address:

Witness #2:

_______________

__________ Printed Name Signature Date

Witness’s Address:

CERTIFICATION OF NOTARY PUBLIC

STATE OF ARIZONA COUNTY OF

On this day of , 20 , before me,

, a notary public the State of Arizona, personally came , personally to me known to be the identical person whose name is affixed to the above health care power of attorney as principal, and, in accordance with the notarial requirements under section 36-3221, Arizona Revised Statutes, I affirm under penalty of perjury that I was present when the principal named in this health care power of attorney dated and signed or marked this document, and that the principal appeared to be of sound mind and free from duress at the time of execution of this health care power of attorney. I further affirm that I am not: (1) designated to make medical decisions on the principal's behalf under this or any other document or health care power of attorney; (2) directly involved with the provision of health care to the principal at the time of execution of this health care power of attorney; (3) related to the principal by blood, marriage or adoption; and (4) entitled to any SIGN SIGN

part of the principal's estate by will or by operation of law at the time that the power of attorney is executed.

Witness my hand and notarial seal at in such county the day and year last above written.

Notarial Seal:

Signature of Notary Public

SPECIAL AUTHENTICATION IF PRINCIPAL IS UNABLE TO SIGN OR MARK As required under section 36-3221, Arizona Revised Statutes, if the principal is physically unable to sign or mark this health care power of attorney, the notary or each witness, by signing on the designated signature lines below, affirm and verify, under penalty of perjury, that the principal directly indicated to the notary or to each witness that the power of attorney: (1) expresses the principal’s wishes, and (2) that the principal intends to adopt the power of attorney at the time of the notary’s certification or the witnesses’ execution of this instrument.

_______________

__________ Printed Name of Witness #1 Signature Date

_______________

__________ Printed Name of Witness #2 Signature Date

or

_______________

__________ Printed Name of Notary Public Signature Date

ACKNOWLEDGMENT OF AGENT BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE LEGAL RESPONSIBILITIES OF AN AGENT. Agent:

_______________

__________ Printed Name Signature Date

Agent’s Address:

SIGN SIGN SIGN SIGN SIGN