Using these forms you may choose someone to make decisions for your medical care in the event you are unable to do so yourself. You may also use these forms to appoint representatives to act for you under health care powers of attorney. Perhaps most importantly, the forms enable you to make your family and friends aware of your choices and wishes.
This form is applicable only for the State of Arizona.
Arizona Advance Directive for Health Care FAQ and Info
Arizona Advance Directive for Health Care Form
Text Version of this Form
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STATE OF ARIZONA
DURABLE HEALTH CARE POWER OF ATTORNEY
Instructions and FormGENERAL 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 decis ions 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: ________________________ Home Telephone: ________________________
Street Address: ________________________ Work Telephone: ________________________
City, State, Zip: ________________________ 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: ________________________ Home Telephone: ________________________
Street Address: ________________________ Work Telephone: ________________________
City, State, Zip: ________________________ 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 decisions 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_______________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 1 DURABLE HEALTH CARE POWER OF ATTORNEY———————– Page 2———————–
DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d)
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 indicate which organs or tissues you want to donate and where you want them
donated. Initial or put a check mark by A or B below. If you select B, continue with your choices._____ A. I DO NOT WANT to make an organ or tissue donation, and I do not want this donation
authorized on my behalf by my representative or my family.
_____ B. I DO WANT to make an organ or tissue donation when I die. Here are my directions:1. What organs/tissues I choose to donate: (Select a or b below) _____ a. Any needed parts or
organs.
_____ b. These parts or organs:
1.) _____________________________________________________
2.) _____________________________________________________
3.) _____________________________________________________2. What purposes I donate organs/tissues for: (Select a, b, or c below)
_____ a. Any legally authorized purpose (transplantation, therapy, medical and dental
evaluation and research, and/or advancement of medical and dental science). _____ b.
Transplant or therapeutic purposes only.
_____ c. Other: _________________________________________________3. What organization or person I want my parts or organs to go to:
_____ a. I have already signed a written agreement or donor card regarding organ and tissue
donation with the following individual or institution: (Name) ______________________
_____________________________________________________________________
_____ b. I would like my tissues or organs to go to the following individual or institution:
(Name) ______________________________________________________________
_____ c. I authorize my representative to make this decision._______________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
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DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d)
7. Funeral and Burial Disposition: (Optional)
My agent has authority to carry out all matters relating to my funeral and burial disposition wishes in accordance
with this power of attorney, which is effective upon my death. My wishes are reflected below:Initial or put a check mark by those choices you wish to select.
_____ Upon my death, I direct my body to be buried. (As opposed to cremated)
_____ Upon my death, I direct my body to be buried in _______________________________________
__________________________________________________________________. (Optional directive)
_____ Upon my death, I direct my body to be cremated.
_____ Upon my death, I direct my body to be cremated with my ashes to be _____________________
__________________________________________________________________. (Optional directive)
_____ My agent will make all funeral and burial disposition decisions. (Optional directive)8. About a Living Will:
NOTE: If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will to
this form. A Living Will form is available on the Attorney General (AG) web site. Initial or put a check mark by box
A or B._____ A. I have SIGNED AND ATTACHED a completed Living Will in addition to this Durable Health Care Power
of Attorney to state decisions I have made about end of life health care if I am unable to communicate
or make my own decisions at that time.
_____ B. I have NOT SIGNED a Living Will.9. About a Prehospital Medical Care Directive or Do Not Resuscitate Directive:
NOTE: A form for the Prehospital Medical Care Directive or Do Not Resuscitate Directive is available on the AG
Web site. Initial or put a check mark by box A or B._____ A. I and my doctor or health care provider HAVE SIGNED a Prehospital Medical Care Directive or Do Not
Resuscitate Directive on paper with ORANGE background in the event that 911 or Emergency Medical
Technicians or hospital emergency personnel are called and my heart or breathing has stopped. _____ B. I
have NOT SIGNED a Prehospital Medical Care Directive or Do Not Resuscitate Directive.HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT/REPRESENTATIVE
_____ (Initial) 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 authority applies
to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42
USC 1320d and 45 CFR 160-164.SIGNATURE OR VERIFICATION
A. I am signing this Durable Health Care Power of Attorney as follows:
My Signature: ____________________________________________ Date: ___________________________
B. I am physically unable to sign this document, so a witness is verifying my desires as follows:
Witness Verification: I believe that this Durable Health Care Power of Attorney accurately expresses the wishes
communicated to me by the principal of this document. He/she intends to adopt this Durable Health Care Power
of Attorney at this time. He/she is physically unable to sign or mark this document at this time, and I verify that
he/she directly indicated to me that the Durable Health Care Power of Attorney expresses his/her wishes and that
he/she intends to adopt the Durable Health Care Power of Attorney at this time._______________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 3 DURABLE HEALTH CARE POWER OF ATTORNEY———————– Page 4———————–
DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d)
Witness Name (printed): _____________________________________________________________________
Signature: ______________________________________________ Date: ____________________________SIGNATURE OF WITNESS OR NOTARY PUBLIC:
NOTE: At least one adult witness OR a Notary Public must witness the signing of this document and then sign it.
The witness or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood,
adoption, or marriage; (c) entitled to any part of your estate; (d) appointed as your representative; or (e) involved
in providing your health care at the time this form is signed.A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who signed
this Durable Health Care Power of Attorney appeared to be of sound mind and under no pressure to make
specific choices or sign the document. I understand the requirements of being a witness and I confirm
the following: I am not currently designated to make medical decisions for this person.
I am not directly involved in administering health care to this person.
I am not entitled to any portion of this person’s estate upon his or her death under a will or by
operation of law.
I am not related to this person by blood, marriage or adoption.Witness Name (printed): _____________________________________________________________________
Signature: ________________________________________________ Date: __________________________
Address: _________________________________________________________________________________Notary Public (NOTE: If a witness signs your form, you DO NOT need a notary to sign):
STATE OF ARIZONA ) ss
COUNTY OF ____________________)The undersigned, being a Notary Public certified in Arizona, declares that the person making this Durable
Health Care Power of Attorney has dated and signed or marked it in my presence and appears to me to be of
sound mind and free from duress. I further declare I am not related to the person signing above by blood, marriage
or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in
providing health care to the person signing. I am not entitled to any part of his/her estate under a will now existing
or by operation of law. In the event the person acknowledging this Durable Health Care Power of Attorney is
physically unable to sign or mark this document, I verify that he/she directly indicated to me that this Durable
Health Care Power of Attorney expresses his/her wishes and that he/she intends to adopt the Durable Health
Care Power of Attorney at this time.
WITNESS MY HAND AND SEAL this ___ day of ______________, 20___.
Notary Public _____________________________________ My Commission Expires: __________________OPTIONAL:
STATEMENT THAT YOU HAVE DISCUSSED
YOUR HEALTH CARE CHOICES FOR THE FUTURE
WITH YOUR PHYSICIANNOTE: Before deciding what health care you want for yourself, you may wish to ask your physician questions
regarding treatment alternatives. This statement from your physician is not required by Arizona law. If you do
speak with your physician, it is a good idea to have him or her complete this section. Ask your doctor to keep a
copy of this form with your medical records._______________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
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DURABLE HEALTH CARE POWER OF ATTORNEY (Last Page)
On this date I reviewed this document with the Principal and discussed any questions regarding the probable
medical consequences of the treatment choices provided above. I agree to comply with the provisions of this
directive, and I will comply with the health care decisions made by the representative unless a decision violates
my conscience. In such case I will promptly disclose my unwillingness to comply and will transfer or try to transfer
patient care to another provider who is willing to act in accordance with the representative’s direction.Doctor Name (printed): ______________________________________________________________________
Signature: ________________________________________________ Date: __________________________
Address: _________________________________________________________________________________
STATE OF ARIZONA
DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY
Instructions and FormGENERAL INSTRUCTIONS: Use this Durable Mental Health Care Power of Attorney form if you want to appoint a
person 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 an Arizona licensed psychiatrist or
psychologist who will evaluate whether you can give informed consent. Be sure you understand the importance of this
document. Talk to your family members, 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.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 more instructions about signing this form on page 3.1. 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 mental health care decisions for me:
Name: ________________________ Home Telephone: ________________________
Street Address: ________________________ Work Telephone: ________________________ City, State,
Zip: ________________________ Cell Telephone: ________________________I choose the following person to act as an alternate representative to make mental health care decisions for me if my
first representative is unavailable, unwilling, or unable to make decisions for me:Name: ________________________ Home Telephone: ________________________
Street Address: ________________________ Work Telephone: ________________________ City, State,
Zip: ________________________ Cell Telephone: ________________________3. Mental health treatments that I AUTHORIZE if I am unable to make decisions for myself:
Here are the mental health treatments I authorize my mental health care representative to make on my behalf if I
become incapable of making my own mental health care decisions due to mental or physical illness, injury, disability,
or incapacity. If my wishes are not clear from this Durable Mental Health Care Power of Attorney or are not otherwise
known to my representative, my representative will, in good faith, act in accordance with my best interests. This_______________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 5 DURABLE HEALTH CARE POWER OF ATTORNEY———————– Page 6———————–
appointment is effective unless and until it is revoked by me or by an order of a court. My representative is authorized
to do the following which I have initialed or marked :_____ A. About my records: To receive information regarding mental health treatment that is proposed for me and
to receive, review, and consent to disclosure of any of my medical records related to that treatment.
_____ B. About medications: To consent to the administration of any medications recommended by my treating
physician.
_____ C. About a structured treatment setting: To admit me to a structured treatment setting with 24hour-a-day
supervision and an intensive treatment program licensed by the Department of Health Services, which is
called a “level one” behavioral health facility.
_____ D. Other: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY (Cont’d)4. Durable Mental health treatments that I expressly DO NOT AUTHORIZE if I am unable to make decisions
for myself: (Explain or write in “None”)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________5. Revocability of this Durable Mental Health Care Power of Attorney: This Durable Mental Health Care Power
of Attorney is made under Arizona law and continues in effect for all who rely upon it except those who have
received oral or written notice of its revocation. Further, I want to be able to revoke this Durable Mental Health
Care Power of Attorney as follows: (Initial or mark A or B.)_____ A. This Durable Mental Health Care Power of Attorney is IRREVOCABLE if I am unable to give informed
consent to mental health treatment.
_____ B. This Durable Mental Health Care Power of Attorney is REVOCABLE at all times if I do any of the following:1.) Make a written revocation of the Durable Mental Health Care Power of Attorney or a written statement to
disqualify my representative or agent.
2.) Orally notify my representative or agent or a mental health care provider that I am revoking.
3.) Make a new Durable Mental Health Care Power of Attorney.
4.) Any other act that demonstrates my specific intent to revoke a Durable Mental Health Care Power of
Attorney or to disqualify my agent.6. Additional information about my mental health care treatment needs (consider including mental or physical
health history, dietary requirements, religious concerns, people to notify and any other matters that you feel are
important):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________HIPPA WAIVER OF CONFIDENTIALITY FOR MY AGENT/REPRESENTATIVE
_____ (Initial) 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 authority applies to
any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC
1320d and 45 CFR 160- 164.SIGNATURE OR VERIFICATION
A. I am signing this Durable Mental Health Care Power of Attorney as follows:
____________________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011 TOM
HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 6 DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY———————– Page 7———————–
My Signature: ____________________________________________ Date: ____________________________
B. I am physically unable to sign this document, so a witness is verifying my desires as follows:
Witness Verification: I believe that this Durable Mental Health Care Power of Attorney accurately expresses the
wishes communicated to me by the Principal of this document. He/she intends to adopt this Durable Mental Health
Care Power of Attorney at this time. He/she is physically unable to sign or mark this document at this time. I verify
that he/she directly indicated to me that the Durable Mental Health Care Power of Attorney expresses his/her
wishes and that he/she intends to adopt the Durable Mental Health Care Power of Attorney at this tim e.Witness Name (printed): _____________________________________________________________________
Signature: ______________________________________________ Date: ____________________________
DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY (Last Page)SIGNATURE OF WITNESS OR NOTARY PUBLIC
NOTE: At least one adult witness OR a Notary Public must witness the signing of this document and then sign it. The
witness or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood, adoption, or
marriage; (c) entitled to any part of your estate; (d) appointed as your representative; or (e) involved in providing your
health care at the time this document is signed.A. Witness: I affirm that I personally know the person signing this Durable Mental Health Care Power of Attorney and
that I witnessed the person sign or acknowledge the person’s signature on this document in my presence. I further
affirm that he/she appears to be of sound mind and not under duress, fraud, or undue influence. He/she is not
related to me by blood, marriage, or adoption and is not a person for whom I directly provide care in a professional
capacity. I have not been appointed as the representative to make medical decisions on his/her behalf.Witness Name (printed): _________________________________________________________________________
Signature: _____________________________________________ Date and time: __________________________
Address: _____________________________________________________________________________________B. Notary Public: (NOTE: If a witness signs your form, you DO NOT need a notary to sign)
STATE OF ARIZONA ) ss
COUNTY OF ____________________)The undersigned, being a Notary Public certified in Arizona, declares that the person making this Durable Mental
Health Care Power of Attorney has dated and signed or marked it in my presence and appears to me to be of
sound mind and free from duress. I further declare I am not related to the person signing above, by blood, marriage
or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in
providing care as a professional to the person signing. I am not entitled to any part of his/her estate under a will
now existing or by operation of law. In the event the person acknowledging this Durable Mental Health Care Power
of Attorney is physically unable to sign or mark this document, I verify that he/she directly indicated to me that the
Durable Mental Health Care Power of Attorney expresses his/her wishes and that he/she intends to adopt the
Durable Mental Health Care Power of Attorney at this time.WITNESS MY HAND AND SEAL this ____ day of ______________, 20___.
Notary Public: _____________________________________ My commission expires: _______________________OPTIONAL:
REPRESENTATIVE’S ACCEPTANCE OF APPOINTMENT____________________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011 TOM
HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 7 DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY———————– Page 8———————–
I accept this appointment and agree to serve as agent to make mental health treatment decisions for the Principal. I
understand that I must act consistently with the wishes of the person I represent as expressed in this Durable Mental
Health Care Power of Attorney or, if not expressed, as otherwise known by me. If I do not know the Principal’s wishes,
I have a duty to act in what I, in good faith, believe to be that person’s best interests. I understand that this document
gives me the authority to make decisions about mental health treatment only while that person has been determined
to be incapacitated which means under Arizona law that a licensed psychiatrist or psychologist has the opinion that
the Principal is unable to give informed consent.Representative Name (printed): ___________________________________________________________________
Signature: __________________________________________________ Date: ________________________________________________________________________________________________________________________________________________
Developed by the Office of Arizona Attorney General Updated January 18, 2011 TOM
HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov 8 DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY———————– Page 9———————–
STATE OF ARIZONA
LIVING WILL (End of Life Care)
Instructions and FormGENERAL INSTRUCTIONS: Use this Living Will form to make decisions now about your medical care if you are ever in a
terminal condition, a persistent vegetative state or an irreversible coma. You should talk to your doctor about what these te rms
mean. The Living Will states what choices you would have made for yourself if you were able to communicate. It is your written
directions to your health care representative if you have one, your family, your physician, and any other person who might be in
a position to make medical care decisions for you. Talk to your family members, 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 complete and sig n
this Living Will.If you decide this is the form you want to use, complete the form. Do not sign the Living Will until your witness or a Notary
Public is present to watch you sign it. There are further instructions for you about signing on page 2.IMPORTANT: If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will to
the Durable Health Care Power of Attorney.1. Information about me: (I am called the “Principal”)
My Name: __________________________________________ My Age: _________________________________
My Address:_________________________________________ My Date of Birth: ___________________________
___________________________________________________ My Telephone: ____________________________2. My decisions about End of Life Care:
NOTE: Here are some general statements about choices you have as to health care you want at the end of your life. They are
listed in the order provided by Arizona law. You can initial any combination of paragraphs A, B, C, and D. If you initial Paragraph
E, do not initial any other paragraphs. Read all of the statements carefully before initialing to indicate your choice. You can
also write your own statement concerning life-sustaining treatments and other matters relating to your health care at Section 3
of this form.______ A. Comfort Care Only: If I have a terminal condition I do not want my life to be prolonged, and I do not want lifesustaining
treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. (NOTE: “Comfort care” means
treatment in an attempt to protect and enhance the quality of life without artificially prolonging life.)______ B. Specific Limitations on Medical Treatments I Want: (NOTE: Initial or mark one or more choices, talk to your doctor
about your choices.) If I have a terminal condition, or am in an irreversible coma or a persistent vegetative state that my doctors
reasonably believe to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep
me comfortable, but I do not want the following:____ 1.) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock, and artificial breathing.
_____ 2.) Artificially administered food and fluids.
_____ 3.) To be taken to a hospital if it is at all avoidable._______ C. Pregnancy: Regardless of any other directions I have given in this Living Will, if I am known to be pregnant I do not
want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth
with the continued application of life-sustaining treatment._______ D. Treatment Until My Medical Condition is Reasonably Known: Regardless of the directions I have made in this
Living Will, I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my
condition is terminal or is irreversible and incurable, or I am in a persistent vegetative state._______ E. Direction to Prolong My Life: I want my life to be prolonged to the greatest extent possible
STATE OF ARIZONA LIVING WILL (“End of Life Care”) (Cont’d)
_______________________________________________________________________________________________________________________________
———————– Page 10———————–
Developed by the Office of the Attorney General Updated January 18, 2011 TOM HORNE (All
documents completed before January 18, 2011 are still valid) www.azag.gov LIVING WILLPage 1 of 2
3. Other Statements Or Wishes I Want Followed For End of Life Care:
NOTE: You can attach additional provisions or limitations on medical care that have not been included in this Living Will form.
Initial or put a check mark by box A or B below. Be sure to include the attachment if you check B._______ A. I have not attached additional special provisions or limitations about End of Life Care I want.
_______ B. I have attached additional special provisions or limitations about End of Life Care I want.
SIGNATURE OR VERIFICATION
A. I am signing this Living Will as follows:
My Signature: ___________________________________________________ Date:
_____________________________B. I am physically unable to sign this Living Will, so a witness is verifying my desires as follows:
Witness Verification: I believe that this Living Will accurately expresses the wishes communicated to me by the principal of this
document. He/she intends to adopt this Living Will at this time. He/she is physically unable to sign or mark this document at this
time. I verify that he/she directly indicated to me that the Living Will expresses his/her wishes and that he/she intends to adopt
the Living Will at this time.Witness Name (printed): ________________________________________________________________________________
Signature: _______________________________________________________ Date: _____________________________
SIGNATURE OF WITNESS OR NOTARY PUBLIC
NOTE: At least one adult witness OR a Notary Public must witness you signing this document and then sign it. The witness
or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood, adoption, or marriage; (c)
entitled to any part of your estate; (d) appointed as your representative; or (e) involved in providing your health care at the time
this document is signed.A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who signed this Living Will
appeared to be of sound mind and under no pressure to make specific choices or sign the document. I understand the
requirements of being a witness. I confirm the following:
♦I am not currently designated to make medical decisions for this person.
♦I am not directly involved in administering health care to this person.
♦I am not entitled to any portion of this person’s estate upon his or her death under a will or by operation of law.
♦I am not related to this person by blood, marriage, or adoption.Witness Name (printed): ___________________________________________________________________________
Signature: __________________________________________________________ Date: ______________________
Address: ________________________________________________________________________________________
B. Notary Public: (NOTE: a Notary Public is only required if no witness signed above)
STATE OF ARIZONA ) ss
COUNTY OF____________________________ )
The undersigned, being a Notary Public certified in Arizona, declares that the person making this Living Will has dated and signed or marked it in
my presence, and appears to me to be of sound mind and free from duress. I further declare I am not related to the person signing above, by
blood, marriage or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in providing health
care to the person signing. I am not entitled to any part of his/her estate under a will now existing or by operation of law. In the event the person
acknowledging this Living Will is physically unable to sign or mark this document, I verify that he/she directly indicated to me that the Living Will
expresses his/her wishes and that he/she intends to adopt the Living Will at this time.WITNESS MY HAND AND SEAL this _______ day of ____________________, 20____.
———————– Page 11———————–
Notary Public: ________________________________________________ My commission expires: _____________________
_______________________________________________________________________________________________________________________________
Developed by the Office of the Attorney General Updated January 18, 2011 TOM HORNE (All
documents completed before January 18, 2011 are still valid) www.azag.gov LIVING WILLPage 2 of 2
STATE OF ARIZONA
LETTER TO MY REPRESENTATIVE(S)
About Powers of Attorney Forms and ResponsibilitiesTo My Representative: To My Alternate Representative:
Name: _______________________________ Name: ________________________________
Address: _____________________________ Address: ______________________________
_____________________________________ _____________________________________A. What I Ask You to Do For Me: Arizona law allows me to make certain medical and financial decisions
as to what I want in the future if I become unable or incapable of making certain decisions for myself. I
have completed the following document(s), and I want you to be my representative or alternate
representative for the following purposes. (Initial or check one or more of the following):______ 1 . Durable Health Care Power of Attorney
______ 2. Durable Mental Health Care Power of Attorney
B. Why I Named an Alternate Representative: I chose two representatives in case one of you is unable
to act for me when the time arises. I ask that you accept my selection of you as my representative or
alternate. If you do not return the Power of Attorney form(s) and this letter to me or inform me differently, I
will assume that you have agreed to be my representative.C. Your Responsibilities as My Representative: By selecting you, I am saying that I want you to make
some very important decisions for me about my future health care needs if I become unable to make these
decisions for myself. I might need you to carry out my medical choices as indicated in the enclosed Powers
of Attorney, even if you do not agree with them. Please read the copies of the Powers of Attorney I am
giving you. This is a very serious responsibility to accept. You will be my voice and will make medical
decisions on my behalf. Other than what I have indicated in the Powers of Attorney as to my specific
directions on certain issues, I am trusting your judgment to make decisions that you believe to be in my
best interests. If at any time you do not feel that you can undertake this responsibility for any reason,
please let me know. If you are unsure about any of my directions, please discuss them with me. If you
are not willing to serve as my representative, please tell me so I can choose someone else to help me.As to Health Care: You are not financially responsible for paying my health care costs merely by accepting
this responsibility. Under Arizona law, you are not liable for complying with my decisions as stated in the
Powers of Attorney or in making other health care decisions for me if you act in good faith.D. What Else You Should Do: Please keep a copy of my Powers of Attorney and other documents in
a safe place. Please read these documents carefully and discuss my choices with me at any time. I will
give copies of my health care Powers of Attorney to my physician, and I will give copies of any or all of
these Powers of Attorney to my family and any other representative I may choose. I authorize you to
discuss with them the Powers of Attorney, including, as applicable, my medical situation, or any medical
concerns about me. Please work with them and help them to act in accordance with my desires and in my
best interests. I appreciate your support, and I thank you for your willingness to help me in this way.———————– Page 12———————–
Signature: _____________________________________ Date: ________________________
Printed Name: ________________________________________________________________
_____________________________________________________________________________________
Developed by the Office of the Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid) www.azag.govLETTER TO REPRESENTATIVE(S) 1
STATE OF ARIZONA
PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE)
(IMPORTANT—THIS DOCUMENT MUST BE ON PAPER WITH ORANGE BACKGROUND)GENERAL INFORMATION AND INSTRUCTIONS: A Prehospital Medical Care Directive is a document signed by you and your doctor
that informs emergency medical technicians (EMTs) or hospital emergency personnel not to resuscitate you. Sometimes
this is called a DNR – Do Not Resuscitate. If you have this form, EMTs and other emergency personnel will not use
equipment, drugs, or devices to restart your heart or breathing, but they will not withhold medical interventions that are
necessary to provide comfort care or to alleviate pain. IMPORTANT: Under Arizona law a Prehospital Medical Care Directive
or DNR must be on letter sized paper or wallet sized paper on an orange background to be valid.You can either attach a picture to this form, or complete the personal information. You must also complete the form and
sign it in front of a witness. Your health care provider and your witness must sign this form.1. My Directive and My Signature:
In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compression,
endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation,
administration of advanced cardiac life support drugs and related emergency medical procedures.Patient (Signature or Mark): ___________________________________________ Date: __________________________
OR
ATTACH RECENT PHOTOGRAPH HERE:
PROVIDE THE FOLLOWING INFORMATION:My Date of Birth ________________________
My Sex ___________________ HERE
My Race ___________________ My Eye Color
___________________ My Hair Color
___________________2. Information About My Doctor and Hospice (if I am in Hospice):
Physician: __________________________________________________________ Telephone: ________________
Hospice Program, if applicable (name): _________________________________________________________________
3. Signature of Doctor or Other Health Care Provider:
I have explained this form and its consequences to the signer and obtained assurance that the signer
understands that death may result from any refused care listed above.Signature, Licensed Health Care Provider: __________________________________________ Date: _______________
———————– Page 13———————–
4. Signature of Witness to My Directive:
I was present when this form was signed (or marked). The patient then appeared to be of sound mind and
free from duress.Signature: ___________________________________________________________________ Date: ________________
_____________________________________________________________________________
______________________________________________________________________________________________________
Developed by the Office of the Arizona Attorney General January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid) www.azag.gov
PREHOSPITAL MEDICAL CARE DIRECTIVE (DNR)
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