Free Arkansas Durable Power Of Attorney For Health Care Form - PDF Form Download
Arkansas Durable Power Of Attorney For Health Care is a legal document signed and executed to appoint an attorney in fact or an agent for taking crucial health care decisions on behalf of the signing principal when the signing principal is incapable of taking decisions for him/her self.
This document is pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20-13-104). The document furthermore provides a source to appoint a secondary agent in case of failure in delivering promised services from the primary agent or attorney in fact. Annulling this legal document is possible only upon revocation by the signing principal and/or death of the signing principal.
Important things to remember
- The power of attorney is pursuant with Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20-13-104)
- Signatures of two neutral witnesses are necessary for execution and legal standing of the Arkansas Durable Power Of Attorney For Health Care
- Use your right to appoint alternate agent using the provision in the power of attorney
- Specifying all the details along with special instructions if any is crucial to avoid ambiguity
- Refer to Ark. Code Ann. § 20-13-104(c) for meaning, scopes, and limitations of the term Healthcare
- Arkansas Rights of the Terminally Ill or Permanently Unconscious Act grants the rights to an agent or an alternate agent to take decisions about health care due to the vegetative state of the signing principal under any or all unforeseen reasons.
The signing principal executing the Arkansas Durable Power Of Attorney For Health Care must begin by typing the legal name, followed by entering the city and county of residence in Arkansas State. The next line requires input of the name of the attorney in fact/agent and his/her residential address. Enter the name of the agent again in the next line and then type the name and address of alternate agent.
Mention the name of the primary attorney in fact in the space provided on the next portion of Arkansas Durable Health Care Power Of Attorney. Write the names of the primary agent and the successor in the respective fields of the foremost portion of page 2 of the document. Next portion of the power of attorney requires the input of name, address of residence, and telephone number of alternate health care agent.
Mention the date of the execution of the power of attorney and sign in the space allocated for the same. Then continue by writing your address on the following lines.
Text Version of the Form
———————– Page 1———————–
I, , of , City of
, County of , Arkansas, hereby make,
constitute and appoint , whose
address is to act as my agent or attorney
in fact, to make health care and related personal decisions for me as
authorized in this document. Should for any
reason be unable or unwilling to act, temporarily or permanently, then I
appoint , of as such agent/attorney in fact,
with the same authority.
This Durable Power Of Attorney is made pursuant to the
Arkansas Durable Power of Attorney for Health Care Act (Ark. Code
Ann. § 20-13-104), and I do hereby designate and appoint
as my agent, or attorney in fact, to make
decisions regarding my health care during periods when my health care
provider has determined that I lack capacity to decide for myself.
Specifically, and not to limit any other rights prescribed under the Act,
my attorney-in-fact shall have the power to have access to my medical
records for treatment or payment decisions; to disclose medical records
to others for purposes of treatment, payment, or health care operations;
to employ and discharge physicians; to consent to or refuse to consent to
medical procedures, including the withholding or withdrawal of life-
sustaining treatment, and nutrition and hydration, according to my
wishes expressed in my Living Will, or, if my wishes are unclear under
the then existing circumstances of my medical condition, then upon
consideration of my best interests as determined by my physician in
consultation with my agent; to admit me to hospitals, including
psychiatric hospitals, nursing homes, or hospice care; and to sign all
appropriate forms, consents and releases in connection with any of said
matters. . If I should either (1) have an incurable or irreversible condition
that will cause my death within a relatively short time and I am no longer
able to make decisions regarding my medical treatment; or (2) if I should
become permanently unconscious, my health care agent and any
alternate health care agent shall also have the authority to make
decisions regarding the providing, withholding or withdrawing of life
sustaining treatment pursuant to the Arkansas Rights of the Terminally
Ill or Permanently Unconscious Act.
———————– Page 2———————–
If resigns, or is not able or available
to make health care decisions for me, or if an agent named by me is
divorced from me or is my spouse and legally separated from me, I
appoint as successor, with all of the rights
and powers and authority herein stated. The term “health care” shall
have the meaning set forth in Ark. Code Ann. § 20-13-104(c) . This
Durable Power of Attorney for Health Care shall not be affected by my
subsequent disability or incapacity.
If the health care agent I appoint is unable, unwilling or
unavailable to act as my health care agent, then I appoint:
(Name, home address and telephone number of alternate agent)
alternate health care agent.
Signed this day of , ____________.
(Day) (Month) (Year)
Statement by Witnesses (must be 18 or older):
I declare that the person who signed this document appeared to
execute the durable power of attorney for health care willingly and free
from duress. He or she signed (or asked another to sign for him or her)
this document in my presence.
(Sign and Print name)
(Sign and Print name)
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