Arizona Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Arizona Durable Medical Power of Attorney Act. It grants the person of your choosing the authority to make healthcare decisions on your behalf should you be incapable of making such decisions for yourself. This document only takes effect under the circumstances specified by Arizona law and remains in effect only as long as those conditions exist.
Part 1: Principal Information
Full Name of Principal: ________________________________________________
Address: ____________________________________________________________
City: ___________________________ State: AZ Zip Code: ___________
Date of Birth: ________________________
Part 2: Agent Information
Full Name of Agent: _________________________________________________
Relationship to Principal: ____________________________________________
Primary Phone: _________________________ Secondary Phone: _________________
Address: ____________________________________________________________
City: ___________________________ State: _____ Zip Code: ____________
Part 3: Alternate Agent Information (Optional)
If the primary agent is unable or unwilling to serve, an alternate agent may act in their place. Including an alternate agent is optional but recommended.
Full Name of Alternate Agent: _________________________________________
Relationship to Principal: _____________________________________________
Primary Phone: _________________________ Secondary Phone: _________________
Address: _____________________________________________________________
City: ___________________________ State: _____ Zip Code: ______________
Part 4: Powers Granted
This document authorizes the agent to make all health care decisions for the principal that the principal could make if capable, subject to any limitations specified in this document. This authority includes, but is not limited to, the power to give or refuse consent to all medical, surgical, hospital, and related health care services.
Part 5: Special Instructions
Here, the principal may specify any limitations on the agent's powers or list particular treatments or care preferences. If additional space is needed, attach separate sheets.
Special Instructions:
_____________________________________________________________________________
_____________________________________________________________________________
Part 6: Signature and Acknowledgment
To be valid, this document must be signed by the principal, or in the principal's name by another individual in the principal's presence and by the principal's expressed direction. It must also be either notarized or witnessed by at least one adult who is neither the agent nor the alternate agent.
Principal's Signature
Date: _______________________ Signature: _______________________________
Agent's Acknowledgment
I, __________________________________, acknowledge my appointment as the agent named in this document. I understand my responsibilities and commit to act in the best interests of the principal, in good faith and according to the principal's wishes and this document's provisions, to the extent known to me.
Date: _______________________ Signature: _______________________________
Alternate Agent's Acknowledgment (If Applicable)
I, __________________________________, acknowledge my appointment as alternate agent named in this document, agreeing to act only if the primary agent resigns, dies, becomes incapacitated, is not qualified to serve, or refuses to serve.
Date: _______________________ Signature: _______________________________
Witness/Notary Acknowledgment
This section should be completed by a Notary Public or by a witness present at the signing of this document.
Notary Public
State of Arizona
County of ___________________________
On this ______ day of ____________, 20__, before me appeared ____________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Date: _______________________ Signature of Notary: _________________________
Seal:
Witness
I declare that the person who signed this document in my presence is personally known to me or has provided satisfactory proof of identity, and that to the best of my knowledge, is of sound mind and under no duress, fraud, or undue influence. I am not the agent or alternate agent named in this document.
Name: ________________________________________
Date: ________________________ Signature: ______________________________