HEALTH CARE POWER OF ATTORNEY
Read the
WARNING! first.
HEALTH CARE POWER OF ATTORNEY
Identification
The name of the person making this health
care power of attorney is:
_________________________ (hereinafter,
"GRANTOR").
The name of the person to whom I give and
grant this health care power of attorney is:
____________________________ (hereinafter,
"AGENT").
The name(s) of the person(s), if any, who
is/are to serve as alternate agents, as described below, is/are as
follows:
_________________________ (hereinafter,
"ALTERNATE 1")
_________________________ (hereinafter,
"ALTERNATE 2")
_________________________ (hereinafter,
"ALTERNATE 3")
If no name is filled in the blank, no such
person is appointed.
Health Care Directives
I, GRANTOR, as principal, designate AGENT
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.
In the event that AGENT is unable or
unwilling to serve or continue to serve in that capacity, for whatever
reason, I hereby appoint as alternate agents, in this order, ALTERNATE 1,
ALTERNATE 2, ALTERNATE 3. If my first named alternate is unable or
unwilling to serve, the second shall assume the duties, to be followed by
the third, if the circumstances should so require.
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 indicated in the living will.
I have _____ I have not _____ completed a
pre-hospital medical directive pursuant to Arizona Revised Statutes,
Section 36-3251.
This power of attorney shall not be
affected by disability of the principal. This power of attorney is made
pursuant to and under Arizona Revised Statutes, Section 14-5501 and shall
continue in effect for all who may rely upon it except those to whom I
have given written notice of its revocation.
This health care directive is also made
pursuant to and under Arizona Revised Statutes, Section 36-3221 and shall
continue in effect for all who may rely upon it except those to whom I
have given written notice of its revocation.
Autopsy
(under Arizona law an autopsy may be
required)
I give the following instructions with
respect to the performance of an autopsy after my death, while fully
understanding that under Arizona law an autopsy may be required in some
circumstances.
[ ] I do not consent to an autopsy.
[ ] I consent to an autopsy.
[ ] My agent may give consent to or refuse
an autopsy.
Organ Donation
I give the following instructions
concerning organ donation after my death:
[ ] I do not want to make an organ or
tissue donation and I do not want my agent or family to do so.
[ ] I wish my agent and my family to have
the authority to make a gift of all or part of my body, and I leave that
decision to their discretion.
[ ] I have already signed a written
agreement or donor card regarding organ and tissue donation with the
following individual or institution: .
[ ] Pursuant to Arizona law, I hereby give,
effective on my death:
[ ] Any needed organ or parts.
[ ] The following part or organs listed:
_________________________
_________________________
_________________________
for:
[ ] Any legally authorized purpose.
[ ] Transplant or therapeutic purposes
only.
GRANTOR's Signature:
__________________________________________
Date:
__________________________________________
Time:
__________________________________________
Address of AGENT:
__________________________________________
Telephone of AGENT:
__________________________________________
Witness Statement
Each witness who signs this health care
power of attorney declares under penalty of perjury that such witness was
present when the GRANTOR dated and signed this health care power of
attorney.
Witness Signature:
__________________________________________
Witness Address:
__________________________________________
Witness Signature:
__________________________________________
Witness Address:
__________________________________________
NOTE: This health care power of attorney
must be notarized or witnessed.
Notarization
STATE OF ARIZONA )
) ss.
County of ______ )
On this the ____ day of ___________, 200__,
GRANTOR and _____________________ and ____________________ personally
appeared before me, the undersigned Notary Public, known to me (or
satisfactorily proven) to be the persons whose names are subscribed to the
foregoing Health Care Power of Attorney and acknowledged that they
executed the same for the purpose therein expressed.
IN WITNESS WHEREOF, I have hereunto set my
hand and official seal.
Notary Public signature:
______________________________
My Commission Expires: _______________ |
