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Arizona Advance Health Care Directive Form 1

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Arizona Advance Health Care Directive Form 1
Arizona Advance Health Care Directive Form 1
1
Arizona Health Care Power of Attorney
Living Will
Directions for Disposition of Body at Death
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
Witness: __________________________________ Date: ____________________
Time: ____________________
Address: ______________________________________________________________________
Arizona Advance Health Care Directive Form 1
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