Arizona Medical Power of Attorney
This Medical Power of Attorney form is designed to comply with Arizona state laws, specifically A.R.S. § 36-3221 to 36-3227. This document allows you to appoint an agent to make healthcare decisions on your behalf in the event that you become unable to make those decisions.
By completing this form, you will ensure that your healthcare preferences are respected and that a trusted individual will be tasked with making decisions in accordance with your wishes.
Principal Information
Principal's Full Name: ____________________________
Principal's Address: ________________________________
City, State, Zip: _________________________________
Date of Birth: _____________________________________
Agent Information
Agent's Full Name: _______________________________
Agent's Address: __________________________________
City, State, Zip: _________________________________
Phone Number: ___________________________________
Alternate Agent (optional)
Alternate Agent's Full Name: ______________________
Alternate Agent's Address: _________________________
City, State, Zip: __________________________________
Phone Number: ___________________________________
Medical Decisions Authority
By signing this document, I authorize my agent to make decisions regarding my medical care, including but not limited to:
- Consent to or refuse medical treatment
- Access my medical records
- Make decisions regarding life-sustaining treatments
- Arrange for care in different medical facilities
This authority shall become effective only when my attending physician determines that I am unable to make my own medical decisions.
Signatures
Principal's Signature: _______________________
Date: ___________________________________
Witness 1's Signature: _____________________
Name and Address: ________________________
Witness 2's Signature: _____________________
Name and Address: ________________________
Notarization (if required)
State of Arizona
County of ________________
Subscribed and sworn before me on this _____ day of ______________, 20___.
Notary Public's Signature: ______________________
My commission expires: _________________________