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Arizona Advance Health Care Directive Form 2

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Arizona Advance Health Care Directive Form 2
Arizona Advance Health Care Directive Form 2
STATE OF ARIZONA
DURABLE HEALTH CARE POWER OF ATTORNEY
Instructions and Form
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:
¾ To consent or to refuse medical care, including diagnostic, surgical, or therapeutic procedures;
¾ 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;
¾ 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 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;
Developed by the Office of the Arizona Attorney General Updated February 12, 2007
TERRY GODDARD (All documents completed before February 12, 2007 are still valid)
www.azag.gov 1 DURABLE HEALTH CARE POWER OF ATTORNEY
GENERAL 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 decisions 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.
Arizona Advance Health Care Directive Form 2
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