Go to Public Legal Home
  • Forms
    • Legal Forms Home
    • Business
    • Buying & Selling
    • Borrowing & Lending
    • Business Ventures
    • Credit & Collection
    • Employment
    • Leases & Real Estate
    • Protection of Rights
    • Transfers & Assigns
    • Personal
    • Last Wills & Estates
    • Marital & Family
    • Name Change
    • Power of Attorney
    • Health Care
  • Profession
    • 350 Largest Law Firms
    • Legal Salaries
    • CLE
    • Lawyers & Firms
    • Legal Associations
    • Legal Experts
    • Legal Forms Sources
    • Business Entity Forms
  • Academics
    • Law School Rankings
    • Law School Profiles
    • Law School Salaries
    • Law School Tuition
    • Law School Outlines
    • External, 3rd Party
    • Rankings Sources
    • Law Journals
    • Law Students
    • Pre-Law
  • Research
    • U.S. State Gov't
    • U.S. Federal Gov't
    • Legal Indices
    • Statutes & Codes
  • About
    • About Us
    • Contact Us
    • Testimonials
    • Terms of Use
    • Privacy Policy
  • Forms
  • Firms
  • Schools
    1. you are here:
    2. forms menu
    3. health care
    4. arizona health
    1. you are here:
    2. forms menu
    3. health care
    4. arizona health care power of
    1. you are here:
    2. forms menu
    3. health care
    4. arizona health care power of attorney

    Arizona Health Care Power of Attorney

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
    • Accuracy guarantee

    ARIZONA 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.

    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 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. The Internet Legal Research Group also has available its Arizona Living Will at https://www.ilrg.com/forms/states/az-livingwill.html.


    (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 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.


    ____________________________________
    Signature of Notary Public


    Notarial Seal:
     

    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.

    Witness #1:

    _____________________________
    Printed Name

    _____________________________
    Signature

    _____________
    Date

    Witness’s Address: ___________________________________________________________


    Witness #2:

    _____________________________
    Printed Name

    _____________________________
    Signature

    _____________
    Date

    Witness’s Address: ___________________________________________________________

    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 of Agent

    _____________________________
    Signature

    _____________
    Date

    Other Forms You May Need

    • Arizona Living Will
    • HIPAA Authorization and Waiver
    • Arizona General Durable Power of Attorney for Property & Finances (Immediate)

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
    • Accuracy guarantee
    "Are these forms valid in my state?" At ILRG, we are committed to delivering top quality legal forms that are valid in all states. We will pay $50 to anyone who brings to our attention any form on our site that is not compliant with U.S. state law. See the terms and conditions for this offer for further information. ILRG guarantees your complete satisfaction with your purchase. If you are not 100 percent satisfied after purchasing from us, contact us for a full refund.

    No Ads, No Affiliates, No Subscription Plans, No Hidden Fees, No Sharing Your Data. PublicLegal is a socially motivated website that provides information about the law while respecting your rights and privacy. View our privacy policy.

    Legal Forms

    Business
    Buying & Selling
    Borrowing & Lending
    Business Ventures
    Credit & Collection
    Employment
    Leases & Real Estate
    Protection of Rights 
    Transfers & Assigns

    Personal
    Last Wills & Estates
    Marital & Family
    Name Change
    Power of Attorney
    Health Care

    Legal Profession

    350 Largest Law Firms
    Legal Salaries
    CLE
    Lawyers & Firms
    Legal Associations
    Legal Experts
    Legal Forms Sources
    Business Entity Forms

    Legal Academics

    Law School Rankings
    Law School Profiles
    Law School Salaries
    Law School Tuition
    Law School Outlines

    External, 3rd Party
    Rankings Sources
    Law Journals
    Law Students
    Pre-Law

    Legal Research

    U.S. State Gov't
    U.S. Federal Gov't
    Legal Indices
    Statutes & Codes



    About

    About Us
    Contact Us
    Testimonials
    Terms of Use
    Privacy Policy

    © 1995-2023 Internet Legal Research Group

    An operating division of Maximilian Ventures LLC

    Reproduction in whole or in part without permission is prohibited.


    TRUSTe