Arizona Medical Power of Attorney
This document grants the power of attorney for medical decisions in the state of Arizona. It is crafted in accordance with the relevant sections of the Arizona Revised Statutes. By signing this document, you (the "Principal") designate a trusted person (the "Agent") to make healthcare decisions on your behalf should you become unable to do so.
Principal Information
Full Name: ___________________________________
Date of Birth: _________________________________
Address: _____________________________________
Agent Information
Full Name of Agent: ____________________________
Relationship to Principal: ______________________
Phone Number: ________________________________
Alternate Phone Number: ________________________
Address: _____________________________________
Alternate Agent Information (Optional)
Full Name of Alternate Agent: ___________________
Relationship to Principal: ______________________
Phone Number: ________________________________
Alternate Phone Number: ________________________
Address: _____________________________________
In the event that the primary Agent is unable or unwilling to serve, the Alternate Agent will assume the powers granted by this document.
Authority of Agent
The Agent is granted the authority to make any and all health care decisions for the Principal that the Principal could make if capable, including, but not limited to, the decision to withhold or discontinue life-sustaining treatment.
Special Instructions
The Principal may also state specific limitations on the Agent's authority or provide special instructions by completing the following:
______________________________________________
______________________________________________
______________________________________________
Signature
By signing this document, the Principal affirms their desire to grant the Agent the powers indicated, unless specifically limited. This document is effective immediately and remains in effect until the Principal's death, unless revoked.
Principal's Signature: __________________________
Date: ________________________________________
Agent's Signature: _____________________________
Date: ________________________________________
Alternate Agent's Signature: ___________________
Date: ________________________________________
Witnesses
State law requires that this document be witnessed by two individuals. Witnesses must not be related to the Principal by blood, marriage, or adoption, and cannot be beneficiaries of the Principal’s estate.
Witness 1 Signature: ___________________________
Date: ________________________________________
Printed Name: _________________________________
Witness 2 Signature: ___________________________
Date: ________________________________________
Printed Name: _________________________________
Notarization (if required or desired)
This section should be completed by a Notary Public.
State of Arizona
County of _________________________
On this day, __________, before me, ________________________(name of notary), personally appeared _________________(name(s) of signatory/parties), known to me (or satisfactorily proven) to be the person(s) whose name(s) is/are subscribed to the within instrument, and acknowledged that he/she/they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Signature: ______________________________
Date: ________________________________________
My Commission Expires: ________________________