LIFE CARE PLANNING
Advance Directives for Making Your Health Care Decisions
Provided by
The Office of Arizona Attorney General,
Kris Mayes
MAIL FORMS TO:
AZ Healthcare Directives Registry
2901 N. Central Ave. Ste. 1100
Phoenix AZ 85012
OR
Email:
documents@azhdr.org
OR
Fax: 602-264-8823
This packet was last updated 01/2023
Office of Attorney General of Arizona,
Life Care Planning:
Information Updated 01/2023
Kris
Mayes
2 of 6
WHAT IS LIFE CARE PLANNING AND WHY IS IT SO IMPORTANT?
Life Care Planning is the process of deciding your medical wishes and who you want to carry them
out, in case you are unable to do so. The documents in this packet are meant for you to express your
wishes, whatever they may be, so you receive the treatment you want if you can no longer
communicate. Hopefully, having your wishes clearly stated will help those close to you avoid the pain
of trying to guess what you would or would not want done.
Life Care Planning is an important task for all of us, whether young or old, healthy or facing
challenges. None of us knows what life has in store, so taking steps to tell our loved ones of our
wishes can make all the difference on our end of life care. Through increased awareness and access
to information, Arizonans of all ages can make their choices known about who will manage their
medical affairs in the event of an emergency.
WHY DOES THE ARIZONA ATTORNEY GENERAL OFFER THESE FORMS?
The Arizona Attorney General’s Office wants to make sure that all Arizonans have access to these
free legal documents, all of which are in line with Arizona Law. The Attorney General’s Office is just
one of several places to get forms and information on life care planning. The Attorney General's
Office is not recommending any particular choices but does urge you to think about these choices,
discuss them with your loved ones, and complete the right documents for your situation.
The primary role of the Attorney General’s Office is to provide legal representation to the State of
Arizona, its agencies, and State officials acting in their official capacities. The Office cannot give legal
advice or represent private citizens on personal legal matters. If you need help with a personal legal
matter—such as filing a lawsuit, creating a will, or defending against a criminal charge—you may
want to contact a private attorney.
TALKING WITH OTHERS ABOUT YOUR WISHES
You should consider the people that you can begin your life care planning conversations with. Your
medical care is about you - start the conversations with those who can help you consider what
medical treatments you may or may not want if you become incapacitated, or as you approach the
end of your life.
Your Health Care Agent (the person you select to make health care decisions for
you)
Your Spouse, Children, Other Relatives, and Close Friends
Your Doctor, Clergyperson and Others
Office of Attorney General of Arizona,
Life Care Planning:
Information Updated 01/2023
Kris
Mayes
3 of 6
DOCUMENTS INCLUDED IN THIS PACKET
Life Care Planning Checklist
o This document lists out all the forms in the packet so that you can check off which ones
you have completed. If you wish to register your documents with the Arizona Health
Care Directives Registry, the checklist will let you know which forms are accepted.
Health Care Power of Attorney
o This form allows you to select a person to make future medical decisions for you if you
become too ill to communicate or cannot make those decisions for yourself.
Living Will
o This form allows you to list out the type of medical treatments you do or do not want for
your end of life care. It should go with your Health Care Power of Attorney form so your
agent knows your wishes.
Mental Health Care Power of Attorney
o This form allows you to select a person to make future mental health care decisions for
you in case you become incapable of making those decisions for yourself.
Prehospital Medical Care Directives (Do Not Resuscitate)
o This form needs to be on orange paper and should be signed by you and your doctor. It
informs emergency medical technicians (EMTs) or first responders not to resuscitate
you. Sometimes this is called a DNR – Do Not Resuscitate. Please note this is valid
prior to going to a hospital, if admitted to a hospital they may require you to fill out
another form for their hospital.
Registration Agreement
o If you would like to register your documents with the Arizona Health Care Directives
Registry, you MUST fill out this form and submit it with your documents.
WHAT DOES THE LAW SAY?
If you are interested in the laws written about the forms in this packet you can look them up at
www.azleg.gov/arstitle/
Health Care Power of Attorney: Arizona Revised Statutes §§ 36-3221 et seq.
Health Care Directives: Arizona Revised Statutes §§ 36-3201 et seq.
Agents or Surrogate Decision-Makers: Arizona Revised Statutes §§ 36-3231 et seq
Living Will: Arizona Revised Statutes §§ 36-3201 et seq AND §§ 36-3261 et seq.
Mental Health Care Power of Attorney: Arizona Revised Statutes §§ 36-3201 et seq AND
§§ 36-3281 et seq.
Prehospital Medical Care Directives (Do Not Resuscitate): Arizona Revised Statutes § 36-3251.
Office of Attorney General of Arizona,
Life Care Planning:
Information Updated 01/2023
Kris Mayes
4 of 6
WHAT TO DO WITH THESE DOCUMENTS IN 4 STEPS
Step 1: Fill out all forms that apply to you and express your wishes for your end of life care.
Read through the documents carefully to select choices that are best suited to your wishes. Each
document will need to be notarized OR witnessed. DO NOT have the documents signed by both, just
pick one. If you do not know a notary or cannot pay for one a witness is legally accepted.
Witnesses or Notary Public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
Step 2: Keep the originals in a safe place that is easily accessible.
It is important to review your documents from time to time. Give copies to the person you choose as
your agent, as well as your doctor and anyone else who may be contacted about your wishes, such
as family members and close friends. Keep a few extra copies and be sure to take one with you if you
go to a hospital or other health care provider.
Step 3: Register your documents on the Arizona Health Care Directives Registry. (Optional)
You can mail, email or fax copies of the documents and the registration form to the registry. The
information to send the documents to is on the cover of this packet and below.
AZ Healthcare Directives Registry
2901 N. Central Ave. Ste. 1100
Phoenix AZ 85012
OR
E
mail: documents@azhdr.org OR Fax: 602-264-8823
The purpose of registering Life Care Planning forms is to create a centralized location where your
relatives, first responders, a hospital, or other health care facility can access the forms if they are not
readily available.
Step 4 – If Needed: Replacing Existing Directives.
To make changes to your existing documents, you will need to complete any forms that are affected
by that change, i.e. change of address, wishes, or agent. It is important that you have a list of people
with copies of your documents so that you can send them all an updated version if needed or a letter
revoking the forms. The state will accept the most recent version of your documents.
If you have registered your documents with the Registry, you will need to fill out another registration
form and indicate that you are replacing, adding, or revoking documents in the Registry.
Office of Attorney General of Arizona,
Life Care Planning:
Information Updated 01/2023
Kris Mayes
5 of 6
LIFE CARE PLANNING IN OTHER STATES
If you have advance directives from another state, district, or territory of the US, Arizona
Revised Statutes §§ 36-3208 et seq says it is “valid in this state if it was valid in the place
where and at the time when it was adopted and only to the extent that it does not conflict with
the criminal laws of this state.”
If you have Arizona advance directives, you will need to check with the Attorney General’s
Office in the other state to find out if they accept Arizona’s documents.
FREQUENTLY ASKED QUESTIONS:
1. Where can I find these free forms?
• You can get copies of this Life Care Planning packet and the individual forms on the
Attorney General’s website at https://www.azag.gov/seniors/life-care-planning, or by calling
the Community Outreach and Education Section at 602-542-2123.
2. If I do not fill out these forms who will make medical decisions for me?
• If you did not leave a Health Care Power of Attorney and there is no court appointed
guardian, health care providers will contact the following people, in this order, who will have
the authority to make health care decisions for you.
• These people are called "surrogates."
1. Your spouse, unless you and your spouse are legally separated.
2. Your adult child. If there is more than one adult child, the health care providers will
seek the consent of a majority of the children who are available for consultation.
3. Your parent.
4. Your domestic partner if no other person has assumed any financial responsibility
for you.
5. Your brother or sister.
6. Your close friend.
3. Should I complete a Do Not Resuscitate "DNR" Form?
• If you are healthy and strong, you may not wish to complete a DNR. You can express your
wishes about how you want to be cared for should you become seriously ill without
completing a DNR. DNRs are most appropriate for people who would probably not do well
with CPR (cardiopulmonary resuscitation) because they are very sick, terminally ill or
otherwise extremely weak. In any case, you will need to discuss the DNR with your doctor,
who will also need to sign the form.
4. At what age should I think about filling out these documents?
• Now, so long as you are at least 18 years of age. It is never too early to be prepared.
Office of Attorney General of Arizona,
Life Care Planning:
Information Updated 01/2023
Kris Mayes
6 of 6
5. Will I need a lawyer to fill out these forms?
• No. You do not need a lawyer’s help to fill out these documents, but you may wish to
consult with a lawyer if you need advice. If you need to find an attorney, you can reach out
to these legal services for help:
• Arizona State Bar
• (602) 252-4804 or www.azbar.org
For help finding an attorney in your budget, area, and skill in the type of help needed.
• 24-hour Senior HELP LINE
• Within Maricopa County - (602) 264-HELP / (602) 264-4357
• Outside Maricopa County – toll free - 1-888-264-2258.
There are Area Agency on Aging regional offices designated to serve each Arizona county.
See your local telephone book for the closest regional office or go to www.des.az.gov and
search Area Agency on Aging for locations.
• Elder Law Hotline
• 1-800-231-5441
Free legal advice, information, and referrals provided o Arizona residents 60 years of age
or older, or to family members calling on behalf of a senior. Attorneys do not provide
services in criminal matters, and do not represent clients in court proceedings. They give
advice, information, and referrals on a wide variety of legal matters important to seniors.
Funded by the Arizona Supreme Court and operated by Southern Arizona Legal Aid, Inc.
WALLET-SIZED NOTICE:
Complete and cut out the notice below. Keep it in your wallet with your driver’s license and
insurance cards so that law enforcement and medical personnel will know who to contact for
copies of your advanced directives.
NOTICE IN CASE OF ACCIDENT OR
EMERGENCY:
My Name:
Date:
I
have signed the following forms: (check)
□ Health Care Power of Attorney
□ Living Will
□ Mental Health Care Power of Attorney
□ Prehospital Medical Directive (Do Not Resuscitate)
Please contact the following for copies:
Name:
Telephone:
LIFE CARE PLANNING
CHECKLIST
Registration Agreement
• This form HAS to be included if you want to register ANY forms.
Health Care Power of Attorney
Living Will
Mental Health Care Power of Attorney
Prehospital Medical Care Directive (Do Not Resuscitate)
To register your completed documents,
make photo copies and send the copies to:
AZ Healthcare Directives Registry
2901 N. Central Ave. Ste. 1100
Phoenix AZ 85012
OR
Email: documents@az
hdr.org
OR
Fax: 602-264-8823
Arizona Healthcare Directives Registry
Health Current | 2901 N. Central Ave., Ste. 1100 | Phoenix, AZ 85012
P: 602-368-6371 | F: 602-264-8823 | azhdr@contexture.org | azhdr.org
REGISTRATION AGREEMENT
How to complete this Agreement:
• Read the agreement and complete this form.
• Fill in all blank spaces on this form.
• Sign and date form.
• Attach a copy of the witnessed or notarized
advance directive(s). DO NOT SEND
ORIGINALS TO THE AZHDR.
• Mail to: AzHDR – Health Current
2901 N. Central Ave., Ste. 1100
Phoenix, AZ 85012
• Or fax to: 602-264-8823
• Or email to: [email protected]
Processing time: up to three weeks.
REQUIRED REGISTRANT INFORMATION
Last Name:
First Name:
Middle Name:
Address:
Date of Birth: MM/DD/YYYY
City:
State:
Zip:
Phone: I choose to opt out of SMS text
Email: I choose to opt out of email
Mailing address if different from above:
City:
State:
Zip:
Check the applicable box (check only one box per submission):
New registration.
Replace an advance directive(s) presently in the AzHDR with the new one(s) attached.
Replace all documents presently in the registry with the new one(s) attached.
Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving
the others in place (check all that apply):
Living will Health care power of attorney Mental health care power of attorney DNR
Add an additional document to my currently stored directive(s).
Inactivate my account: Check this box if you do not want your documents to be active in the registry.
Change registrant demographic information previously submitted (update your information on this form).
Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once
your account has been activated and your documents have been uploaded to the AzHDR, Health Current will
not retain paper copies of your advance directives. Additionally, any documents received by Health Current
that are not advance directives or attachments thereto will not be accepted and will be shredded and securely
destroyed.
©2022 Contexture. All rights reserved.
2
Arizona Advance Directives Registration Agreement
Terms & Conditions
1. The AzHDR. The AzHDR is a free online registry for securely storing and accessing advance directives electronically. The Arizona Department
of Health Services (“ADHS”) has designated Health Current to operate the AzHDR. (see A.R.S. §§ 36-3291 through 3297). Health Current has contracted
with a technology vendor(s) (“Vendor”) to power this service. Use of the AzHDR is voluntary. Your decision to submit (or not submit) documents to
the AzHDR will NOT affect the validity or revocation of any advance directives. While Health Current and its Vendor enable individuals to submit,
store and access advance directives, Health Current and its Vendor do not take any part in, and are not responsible for, whether or how these advance
directives are used or any interactions between you and third parties.
2. Submitting Advance Directives.
(a) Advance Directives. The documents that may be submitted to the AzHDR are limited to health care powers of attorney, mental healthcare powers
of attorney, living wills, and prehospital medical care directives, as well as any attachments and any amendments thereto (collectively, “advance
directives”). Arizona law requires that documents submitted to the AzHDR be notarized or witnessed. You must NOT submit any original
documents to the AzHDR. Original documents may not be returned. All documents submitted must be copies. Once accessible in the
AzHDR, any paper documentation submitted to Health Current will be shredded and securely destroyed. Health Current will not retain
paper copies of your advance directives.
(b) Representation and Warranty. You represent and warrant that the information you provide to us is accurate, current and complete. This is an
ongoing representation and warranty. You must not misrepresent your identity, provide false information, impersonate another person, or misrepresent
your relationship with a person.
(c) Consent. By submitting documents to the AzHDR, you are giving your permission for Health Current to store these documents and make them
accessible to third parties subject to applicable law. You must follow all the laws that apply to you regarding the release of information to the AzHDR.
You are solely responsible for obtaining and any all consents or authorizations that you determine are required by the laws that apply to you to release
information (including without limitation advance directives) to the AzHDR (collectively, “Consent”).
(d) Activation. You acknowledge and agree that in order to activate your submission of an advance directive to the AzHDR, we must receive
confirmation that the information submitted is correct. We may ask you for that confirmation. If applicable to your submission, you acknowledge, agree
and authorize Health Current to provide your submission and the details surrounding that submission to the person who is the subject of the advance
directive. You further authorize us to contact that person using the contact information you have provided to us. For example, if you are submitting an
advance directive for another person, and you give us that person’s physical address, email address or telephone phone number, you authorize us to use
that contact information to inform that person that you have submitted an advance directive about that person.
(e) Identity Verification. Before we activate your document submission(s), we will also require you to verify your identity. In order to do that, you will
be required to provide certain personal information about yourself and may be asked to provide personal information about the person who is the
subject of the advance directive if you are submitting the advance directive for someone other than yourself. If you submit this Agreement and your
advance directive by fax or mail to Health Current, you will be required to have your signature notarized to verify your identity. By signing this agreement
before a notary public, you hereby consent to this form of identity verification. You represent and warrant that you have obtained any and all Consents
to provide personal information about another person as part of your submission.
(f) No Document Validation. You acknowledge that Health Current has no obligation to pre-screen, verify or validate the advance directive(s) or any
other documents you submit to the AzHDR; however, we reserve the right in our sole discretion to pre-screen, refuse to activate, or remove any
document if it violates this Registration Agreement or is otherwise objectionable.
3. Accessing Advance Directives.
(a) Your AzHDR Account. Once we receive your document submission, we will create an AzHDR account that you can claim by registering with us
at signup.azhdr.org You may review, retrieve, revoke and replace documents through your AzHDR account or by contacting us at [email protected] It
may take up to three weeks for us to process a request. A revocation or replacement is not effective until it is processed, and it will not affect any access,
disclosure, use or other action taken in reliance on a previously submitted document before the effective date of the change.
(b) Security. Health Current uses industry standard safeguards to ensure the security, privacy and integrity of the AzHDR, but we need your help. You
must protect your AzHDR account information and credentials. Health Current and its Vendor will not be responsible for any loss or damage caused
by someone else using your account.
(c) Privacy. Health Current will not use or disclose information we maintain for the AzHDR except as allowed by state or federal law, including the
AzHDR Confidentiality Law (see A.R.S. § 36-3295). Please read the Privacy Policy on the AzHDR website (azhdr.org) to learn how information about
you is collected, used, and shared in connection with the AzHDR. By signing this Registration Agreement or by submitting documents to the AzHDR,
you are also agreeing to the Privacy Policy. The Privacy Policy (and changes to it) are incorporated by reference into these Terms & Conditions.
(d) DISCLAIMER. HEALTH CURRENT AND ITS VENDOR DO NOT GUARANTEE THAT INFORMATION (INCLUDING WITHOUT
LIMITATION ADVANCE DIRECTIVES) ON OR ACCESSIBLE THROUGH THE AZHDR WILL BE ACCURATE, COMPLETE, TIMELY
(REAL TIME OR CONTINUOUSLY), ERROR-FREE, SECURE, OR WITHOUT INTERRUPTIONS, OR THAT ANY ERRORS WILL BE
CORRECTED. YOU UNDERSTAND AND AGREE THAT THE AZHDR IS PROVIDED “AS IS” AND “AS IS AVAILABLE” WITH ALL
FAULTS. NEITHER HEALTH CURRENT NOR VENDOR SHALL BE LIABLE FOR THE LOSS, DESTRUCTION OR UNAVAILABILITY
OF ALL OR PART OF YOUR SUBMITTED DOCUMENTS.
4. Electronic Communications. By giving us your contact information, you are agreeing to receive communications, including without limitation
calls, emails, text messages and notifications, from Health Current, Vendor and/or our affiliates about the document(s) you submitted and/or your use
of the AzHDR, including without limitation notices and advisories. These communications may be done by automated dialing equipment and/or artificial
voice or prerecorded messages. You may receive multiple messages each day. Standard message and data rates apply. We are not responsible for any
data transmission fees. You can opt out at any time from receiving text messages by replying “STOP.” This opt-out process does not apply to live phone
calls or emails, which may continue in case we need to reach you.
5. Limitations of Liability. YOU UNDERSTAND AND AGREE THAT HEALTH CURRENT, ITS MEMBERS, OFFICERS, DIRECTORS,
REPRESENTATIVES, EMPLOYEES, AGENTS, AFFILIATES, VENDOR AND BUSINESS PARTNERS (COLLECTIVELY, “HEALTH
©2022 Contexture. All rights reserved.
3
CURRENT PERSONNEL”), WILL NOT BE LIABLE TO YOU OR ANYONE ELSE FOR ANY INDIRECT, INCIDENTAL,
CONSEQUENTIAL (INCLUDING WITHOUT LIMITATION LOST REVENUES OR LOST PROFITS), PUNITIVE, OR EXEMPLARY
DAMAGES, PENALTIES, OR SPECIAL LIABILITY ARISING OUT OF OR IN ANY WAY CONNECTED WITH YOUR DOCUMENT
SUBMISSIONS. IN NO EVENT WILL HEALTH CURRENT PERSONNEL’S LIABILTY ARISING OUT OF OR RELATED TO USE OF THE
AZHDR EXCEED $50.00. ANY CAUSE OF ACTION OR CLAIM YOU MAY HAVE ARISING OUT OF OR IN ANY WAY CONNECTED
TO YOUR DOCUMENT SUBMISSION MUST BE COMMENCED WITHIN ONE (1) YEAR AFTER THE CAUSE OF ACTION ACCRUES,
OTHERWISE SUCH CAUSE OF ACTION OR CLAIM IS PERMANENTLY BARRED. YOU ACKNOWLEDGE AND AGREE THAT
HEALTH CURRENT PERSONNEL ARE NOT LIABLE, AND YOU AGREE NOT TO SEEK TO HOLD THEM LIABLE, FOR THE
CONDUCT OF THIRD PARTIES. THE FOREGOING LIMITATIONS WILL APPLY WHETHER SUCH DAMAGES, LIABILITY, CAUSES
OF ACTION OR CLAIMS ARISE OUT OF BREACH OF CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHERWISE, AND
REGARDLESS OF WHETHER SUCH DAMAGES, LIABILITY, CAUSES OF ACTION OR CLAIMS WERE FORESEEABLE OR HEALTH
CURRENT PERSONNEL WERE ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, LIABILITY, CAUSES OF ACTION OR CLAIMS.
6. Indemnification and Release. YOU AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS HEALTH CURRENT
PERSONNEL FROM ANY AND ALL CLAIMS, DEMANDS, ACTIONS OF ANY KIND, LOSSES, EXPENSES, DAMAGES AND COSTS
(INCLUDING WITHOUT LIMITATIONS REASONABLE ATTORNEYS’ FEES) (COLLECTIVELY, “LOSSES”) ARISING OUT OF OR IN
ANY WAY CONNECTED WITH YOUR DOCUMENT SUBMISSIONS. You further agree to release Health Current Personnel and their successors
from any and all Losses (including without limitation personal injuries and death) arising out of or in any way connected with the actions or omissions
of third parties in connection with the AzHDR.
7. CLASS ACTION AND JURY TRIAL WAIVER. YOU AGREE THAT DISPUTES BETWEEN YOU AND HEALTH CURRENT OR
ITS VENDOR WILL BE RESOLVED IN ACCORDANCE WITH THIS SUBMISSION AGREEMENT AND YOU WAIVE YOUR RIGHT TO
PARTICIPATE IN A CLASS OR COLLECTIVE ACTION LAWSUIT, OR CLASS OR COLLECTIVE ARBITRATION. YOU AND HEALTH
CURRENT WAIVE ALL RIGHTS TO A JURY TRIAL AND ELECT INSTEAD TO HAVE A JUDGE RESOLVE THE DISPUTE.
8. Miscellaneous. If any provision of this Submission Agreement is found to be unenforceable or invalid, such provisions will be deleted without
affecting the remaining provisions. Arizona law governs the interpretation of this Registration Agreement, and will apply if there are disputes. Disputes
will be settled in Maricopa County, Arizona, and you agree to submit to the exclusive personal jurisdiction of state and federal courts located in Maricopa
County, Arizona.
Registrant Attestation (NOTARIZATION REQUIRED)
By signing below, I certify that I have read, understand, and agree to this AzHDR Registration Agreement, including without limitation
the Terms and Conditions contained herein. I understand that once a submitted document is activated, it may be accessible to healthcare
providers for the provision of healthcare services. I acknowledge and affirm that:
• I am eighteen (18) years of age or older or am an emancipated minor.
• I signed and executed the accompanying advance directive(s) and did so willingly (or willingly directed another to sign for me)
as my free and voluntary act for the purposes therein expressed;
• The information provided is true and accurate to the best of my knowledge.
Signature: ____________________________________________ Date: ____________________________
Printed Name of Signer: __________________________________
Select the one that applies:
I am the subject of the advance directive.
I have the following relationship to the subject of the advance directive: ______________________
State of Arizona
County of ____________________
On this _______ day of __________________, 20____, before me personally appeared
__________________________________________ (name of signatory), whose identity was proved to me on the
basis of satisfactory identification/evidence to be the person whose name is subscribed to this document.
(Seal)
______________________________
Signature of Notary Public
©2022 Contexture. All rights reserved.
Office of Arizona Attorney General, Life Care Planning: Health Care
Power of Attorney– Updated 01/2023
Kris Mayes
1 of 5
HEALTH CARE POWER OF ATTORNEY
Instructions and Information
GENERAL INSTRUCTIONS: Use this form if you want to select a person, called an “agent”, 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. Be sure you
understand the importance of this document. It is a good idea to talk to your doctor and loved ones if
you have questions about the type of health care you do or do not want.
AUTOPSY CHOICE: If there is no legal reason to require an autopsy, you can decide if you want one
done when you die, or whether you want your agent to choose for you. There is usually a charge for
voluntary autopsies. You can help your family and loved ones by making your preferences on this
topic clear. For additional information on autopsies please review Arizona Revised Statutes §§ 11-
591 and 11-597.
ORGAN DONATION CHOICE (OPTIONAL): You can determine if you want to donate organs or
tissues, and if you do, what organs or tissues you want to donate, for what purposes, and to what
organizations. You also have the option of whole-body donation for research purposes. You can also
choose to have your agent decide. For additional information on Organ Donation, please review
Arizona Revised Statutes §§ Title 36, Chapter 7, Article 3 for the laws that pertain to it.
FUNERAL AND BURIAL CHOICE (OPTIONAL): You can determine, your funeral and burial
choices in this form. You can select if, upon your death, you would like to be buried and where, or if
you would like to be cremated and where your ashes will go, or you can select your agent to make
that choice.
If you fill out this form, make sure you DO NOT SIGN UNTIL your witness or a notary public is
present to watch you sign it.
PLEASE NOTE: At least one adult witness, not to include the proxy if there is one, OR a notary public
must witness you signing this document.
DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one, a witness is legally accepted.
Witnesses or notary public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
Office of Arizona Attorney General, Life Care Planning: Health Care
Power of Attorney– Updated 01/2023 Kris Mayes
2 of 5
OFFICE OF THE ARIZONA ATTORNEY GENERAL
KRIS MAYES
Health Care Power of
Attorney
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Selection of my health care power of attorney and alternate:
I choose the following person to act as my agent to make health care decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: _________________________
____________________________ Cell Phone: __________________________
I choose the following person to act as an alternate to make health care decisions for me if my first
agent is unavailable, unwilling, or unable to make decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: __________________________
____________________________ Cell Phone: ___________________________
I AUTHORIZE my agent to make health care decisions for me when I cannot make or communicate
my own health care decisions. I want my agent to make all such decisions for me except any
decisions that I have expressly stated in this form that I do not authorize him/her to make. My agent
should explain to me any choices he or she made if I am able to understand. I further authorize my
agent to have access to my “personal protected health care information and medical records”. This
appointment is effective unless it is revoked by me or by a court order.
Health care decisions that I expressly DO NOT AUTHORIZE if I am unable to make decisions
for myself: (Explain or write in "None")
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
My specific wishes regarding autopsy (additional information on page 1):
*Please note that if not required by law a voluntary autopsy may cost money. Initial your choice.
_____: Upon my death I DO NOT consent to a voluntary autopsy.
_____: Upon my death I DO consent to a voluntary autopsy.
_____: My agent may give or refuse consent for an autopsy.
Office of Arizona Attorney General, Life Care Planning: Health Care
Power of Attorney– Updated 01/2023 Kris Mayes
3 of 5
My specific wishes regarding organ donation (additional information on page 1):
If you do not initial this section your agent may make these decisions for you. Initial your choice.
_____: I DO NOT WANT to make an organ or tissue donation, and I DO NOT want this donation
authorized on my behalf by my agent or my family.
_____: I have already signed a written agreement or donor card regarding donation with the following
individual or institution: ________________________________________________________
_____: I DO WANT to make an organ or tissue donation when I die. Here are my directions:
1. What organs/tissues I choose to donate (initial below):
a. _____: Whole body
b. _____: Any needed parts or organs
c. _____: These parts or organs only:
i. _____________________________________________________________________________
2. I am donating organs/tissue for (initial below):
a. _____: Any legally authorized purpose
b. _____: Transplant or therapeutic purposes only
c. _____: Research only
d. _____: Other: _______________________________________________________
3. The organization or person I want my organs/tissue to go to are (initial below):
a. _____: _____________________________________________________________
b. _____: Any that my agent chooses
My specific wishes regarding funeral and burial disposition (additional information on page 1):
_____: Upon my death, I direct my body to be buried. (Instead of cremated)
_____: Upon my death, I direct my body to be buried in: ____________________________________
_____: Upon my death, I direct my body to be cremated.
_____: Upon my death, I direct my body to be cremated with my ashes to be ___________________
__________________________________________________________________________
_____: My agent will make all funeral and burial decisions.
Office of Arizona Attorney General, Life Care Planning: Health Care
Power of Attorney– Updated 01/2023 Kris Mayes
4 of 5
Do you have a living will?
If you have a Living Will, you must attach the Living Will to this form. A blank Living Will is available
on the Attorney General’s website www.azag.gov. Initial below.
_____: I have SIGNED AND ATTACHED a completed Living Will to this Health Care Power of Attorney.
_____: I have NOT SIGNED a Living Will.
Do you have a POLST (Portable Medical Order)?
A POLST form is for when you become seriously ill or frail and toward the end of life. A blank POLST
is available on the Attorney General’s website www.azag.gov. Initial below.
_____: I have SIGNED AND ATTACHED a completed POLST to this Health Care Power of Attorney.
_____: I have NOT SIGNED a POLST.
Do you have a Prehospital Medical Care Directive – a type of Do Not Resuscitate form (DNR)?
A blank Prehospital Medical Care Directive or DNR is available on the Attorney General’s website
www.azag.gov. Initial below.
_____: I and my doctor or health care provider HAVE SIGNED a Prehospital Medical Care Directive or
DNR on Paper with ORANGE background in the event that Emergency Medical Technicians
or hospital emergency personnel are called and my heart or breathing has stopped.
_____: I have NOT SIGNED a Prehospital Medical Care Directive or DNR.
PHYSICIAN AFFIDAVIT (OPTIONAL)
You may wish to ask questions of your physician regarding a particular treatment or about the options
in the form. If you do speak with your physician it is a good idea to ask your physician to complete
this affidavit and keep a copy for his/her file.
I, Dr. ___________________________ have reviewed this document and have discussed with
_______________ any questions regarding the probable medical consequences of the treatment
choices provided above. This discussion with the principal occurred on this day ________________.
I have agreed to comply with the provisions of this directive.
___________________________
Signature of Physician
HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT
_____ (Initial) I intend for my agent to be treated as I would be with respect to my rights regarding
the use and disclosure of my individually identifiable health information or other medical
records. This release authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.
Office of Arizona Attorney General, Life Care Planning: Health Care
Power of Attorney– Updated 01/2023
Kris Mayes
5 of 5
Revocability of this Health Care Power of Attorney: I retain the right to revoke all or any portion of
this form or to disqualify any agent designated by me in this document.
MY SIGNATURE VERIFICATION FOR THE HEALTH CARE POWER OF ATTORNEY
My Signature (Principal): _____________________________________ Date: _________________
If you are unable to physically sign this document, your witness/notary may sign and initial for
you. If applicable have your witness/notary sign below.
Witness/Notary Verification: The principal of this document directly indicated to me that this Health
Care Power of Attorney expresses their wishes and that they intend to adopt it at this time.
Witness/Notary Signature: __________________________________________________________
Name Printed: ______________________________________________ Date: _________________
SIGNATURE OF WITNESS (See Page 1 for who CANNOT be a witness)
I was present when this form was signed (or marked). The principal appeared to be of sound mind
and was not forced to sign this form. I affirm that I meet the requirements to be a witness as indicated
on page one of the health care power of attorney form.
Witness Signature: __________________________________________ Date: ________________
Name Printed: ____________________________________________________________________
Address: _________________________________________________________________________
OR
SIGNATURE OF NOTARY (See Page 1 for who CANNOT be a Notary)
Notary Public (NOTE: If a witness signs your form, you SHOULD NOT have a notary sign):
NOTORIAL JURAT: Pertains to all five pages of this Health Care Power of Attorney
Dated ____________, 20____________.
STATE OF ARIZONA) ss
COUNTY OF ______________)
________________________________________________
Principal’s Name
Subscribed and sworn (or affirmed) before me this ___________ day of ________, 20 ______
Notary Public Signature: ____________________________________
My Commission Expires: ____________________________________
Life Care Planning:
Living Will – Updated 01/2023
1 of 3
LIVING WILL (End of Life Care)
Instructions
GENERAL INSTRUCTIONS: Use this form to make decisions now about your medical care if you are
ever in a terminal condition, a persistent vegetative state or an irreversible coma. You should talk to
your doctor about what these terms mean.
The Living Will is your written directions to your health care power of attorney, also referred to as your
“agent”, your family, your physician, and any other person who might make medical care decisions for
you if you are unable to communicate yourself.
It is a good idea to talk to your doctor and loved ones if you have questions about the type of care you
do or do not want.
IMPORTANT: If you have a Living Will and a Health Care Power of Attorney, you must attach
the Living Will to the Health Care Power of Attorney.
If you fill out this form, make sure you DO NOT SIGN UNTIL your witness or a notary public is
present to watch you sign it.
PLEASE NOTE: At least one adult witness, not to include the proxy if there is one, OR a notary public
must witness you signing this document.
DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one a witness is legally accepted.
Witnesses or notary public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning:
Living Will – Updated 01/2023
2 of 3
OFFICE
OF THE ARIZONA ATTORNEY GENERAL
KRIS MAYES
Living Will
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Some general statements about your health care choices are listed below. If you agree with one of
the statements, you should initial that statement. Read all of these statements carefully BEFORE you
initial your preferred statement. You can also write your own statement concerning life-sustaining
treatment and other matters relating to your health care. You may initial any combination of
paragraphs 1, 2, 3 and 4, BUT if you initial paragraph 5 the others should not be initialed.
_____ 1. If I have a terminal condition I do not want my life to be prolonged, and I do not want life-
sustaining treatment, beyond comfort care, that would serve only to artificially delay the
moment of my death.
**Comfort care is treatment given in an attempt to protect and enhance the
quality of life without artificially prolonging life.
_____ 2. If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my
doctors reasonably feel to be irreversible or incurable, I do want the medical treatment
necessary to provide care that would keep me comfortable, but I DO NOT want the
following:
_____ a. Cardiopulmonary resuscitation (CPR). For example: the use of drugs, electric
shock and artificial breathing.
_____ b. Artificially administered food and fluids.
_____ c. To be taken to a hospital if at all avoidable.
_____ 3. Regardless of any other directions I have given in this Living Will, if I am known to be
pregnant, I do not want life-sustaining treatment withheld or withdrawn if it is possible that
the embryo/fetus will develop to the point of live birth with the continued application of life-
sustaining treatment.
_____ 4. Regardless of any other directions I have given in this Living Will, I do want the use of all
medical care necessary to treat my condition until my doctors reasonably conclude that my
condition is terminal or is irreversible and incurable or I am in a persistent vegetative state.
_____ 5. I want my life to be prolonged to the greatest extent possible (If you initial here, you should
not initial any of the others).
PLEASE NOTE: You can attach additional instructions on your medical care wishes that have not
been included in this Living Will form. Initial or put a check mark by box A or B below. Be sure to
include the attachment if you check B.
_____ A. I HAVE NOT attached additional special instructions about End of Life Care I want.
_____ B. I HAVE attached additional special provisions or limitations about End of Life Care I want.
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning:
Living Will – Updated 01/2023
3 of 3
MY SIGNATURE VERIFICATION FOR THE LIVING WILL
My Signature (Principal): _____________________________________ Date: _________________
If you are unable to physically sign this document your witness/notary may sign and initial for
you. If applicable, have your witness/notary sign below.
Witness/Notary Verification: The principal of this document directly indicated to me that this Living Will
expresses their wishes and that they intend to adopt it at this time.
Witness/Notary Signature: __________________________________________________________
Name Printed: ______________________________________________ Date: _________________
SIGNATURE OF WITNESS
I was present when this form was signed (or marked). The principal appeared to be of sound mind
and was not forced to sign this form.
Witness Signature: __________________________________________ Date: ________________
Name Printed: ____________________________________________________________________
Address: _________________________________________________________________________
OR
SIGNATURE OF NOTARY
Notary Public (NOTE: If a witness signs your form, you SHOULD NOT have a notary sign):
NOTORIAL JURAT: Pertains to all three pages of this Living Will
Dated ____________, 20____________.
STATE OF ARIZONA) ss
COUNTY OF ______________)
________________________________________________
Principals Name
Subscribed and sworn (or affirmed) before me this ___________ day of ________, 20 ______
Notary Public Signature: ____________________________________
My Commission Expires: _____________________
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning: Mental Health Care
Power of Attorney– Updated 01/2023
1 of 3
OFFICE OF THE ARIZONA ATTORNEY GENERAL
KRIS MAYES
Mental Health Care Power of Attorney
GENERAL INSTRUCTIONS: Use this form if you want to appoint a person, also referred to as your
“agent”, to make future mental health care decisions for you if you become incapable of making those
decisions for yourself.
The decision about whether you are incapable can only be made by a specialist in neurology or an
Arizona licensed psychiatrist or psychologist who will evaluate whether you can give informed
consent. Be sure you understand the importance of this document. It is a good idea to talk to your
doctor and loved ones if you have questions about the type of mental health care you do or do not
want.
If you fill out this form, make sure you DO NOT SIGN UNTIL your witness or a notary public is
present to watch you sign it. PLEASE NOTE: At least one adult witness OR a notary public must
witness you signing this document.
DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one, a witness is legally accepted.
Witnesses or notary public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Selection of my mental health care power of attorney and alternate:
I choose the following person to act as my agent to make mental health care decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: _________________________
____________________________ Cell Phone: __________________________
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning: Mental Health Care
Power of Attorney– Updated 01/2023
2 of 3
I choose the following person to act as an alternate to make mental health care decisions for me if my
first agent is unavailable, unwilling, or unable to make decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: __________________________
____________________________ Cell Phone: ___________________________
Mental health treatments that I AUTHORIZE if I am unable to make decisions for myself:
Here are the mental health treatments I authorize my agent to make for me if I become incapable of
making my own mental health care decisions due to mental or physical illness, injury, disability, or
incapacity. This appointment is effective unless and until it is revoked by me or by an order of a court.
My agent is authorized to do the following which I have initialed or marked:
_____: To receive medical records and information regarding my mental health treatment and to receive,
review, and consent to disclosure of any of my medical records related to that treatment.
_____: To consent to the administration of any medications recommended by my treating physician.
_____: To admit me to an inpatient or partial psychiatric hospitalization program.
_____: Other: ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Mental health care treatments that I expressly DO NOT AUTHORIZE if I am unable to make
decisions for myself: (Explain or write in "None")
_____________________________________________________________________________
_____________________________________________________________________________
Revocability of this Mental Health Care Power of Attorney: This mental health care power of
attorney or any portion of it may not be revoked and any designated agent may not be disqualified by
me during times that I am found to be unable to give informed consent. However, at all other times I
retain the right to revoke all or any portion of this mental health care power of attorney or to disqualify
any agent designated by me in this document.
HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT
_____ (Initial) I intend for my agent to be treated as I would be with respect to my rights regarding
the use and disclosure of my individually identifiable health information or other medical
records. This release of authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning: Mental Health Care
Power of Attorney– Updated 01/2023
3 of 3
MY SIGNATURE VERIFICATION FOR THE MENTAL HEALTH CARE POWER OF ATTORNEY
My Signature (Principal): _____________________________________ Date: _________________
If you are unable to physically sign this document your witness/notary may sign and initial for
you. If applicable, have your witness/notary sign below.
Witness/Notary Verification: The principal of this document directly indicated to me that this Health
Care Power of Attorney expresses their wishes and that they intend to adopt it at this time.
Witness/Notary Signature: __________________________________________________________
Name Printed: ______________________________________________ Date: _________________
SIGNATURE OF WITNESS (See Page 1 for who CANNOT be a witness)
I was present when this form was signed (or marked). The principal appeared to be of sound mind
and was not forced to sign this form. I affirm that I meet the requirements to be a witness as indicated
on page one of the mental health care power of attorney form.
Witness Signature: __________________________________________ Date: ________________
Name Printed: ____________________________________________________________________
Address: _________________________________________________________________________
OR
SIGNATURE OF NOTARY (See Page 1 for who CANNOT be a Notary)
Notary Public (NOTE: If a witness signs your form, you SHOULD NOT have a notary sign):
NOTORIAL JURAT: Pertains to all three pages of this State of Arizona Mental Health Care
Power of Attorney dated ____________, 20____________.
STATE OF ARIZONA) ss
COUNTY OF ______________)
________________________________________________
Principal’s Name
Subscribed and sworn (or affirmed) before me this ___________ day of ________, 20 ______
Notary Public Signature: ____________________________________
My Commission Expires: ____________________________________
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning:
DNR - Updated 01/2023
1 of 2
P
REHOSPITAL MEDICAL CARE DIRECTIVE
(DO NOT RESUSCITATE or DNR)
(IMPORTANT – THIS DOCUMENT MUST BE ON PAPER WITH ORANGE BACKGROUND)
MAKE SURE YOU DISPLAY THIS FORM AS VISIBLY AS
POSSIBLE FOR FIRST RESPONDERS
GENERAL INFORMATION AND INSTRUCTIONS: A Prehospital Medical Care Directive is a
document signed by you and your doctor that informs emergency medical technicians (EMTs) or
hospital emergency personnel not to resuscitate you. Sometimes this is called a DNR – Do Not
Resuscitate. If you have this form, EMTs and other emergency personnel will not use equipment,
drugs, or devices to restart your heart or breathing, but they will not withhold medical interventions
that are necessary to provide comfort care or to alleviate pain.
You can either attach a picture to this form OR complete the personal information.
Please take the time to fill out a Health Care Power of Attorney form. That way, if you are unable
to communicate your wishes, your agent can sign this form on your behalf, if that is your wish.
This form must be signed by you, in front of your witness or notary. Your Health Care Provider and
your witness or notary must also sign this form.
DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one, a witness is legally accepted.
Witnesses or notary public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
IMPORTANT: Under Arizona law a Prehospital Medical Care Directive or DNR must be on letter
sized paper or wallet sized paper on an orange background to be valid.
Office of Arizona Attorney General,
Kris Mayes
Life Care Planning:
DNR - Updated 01/2023
2 of 2
PREHOSPITAL MEDICAL CARE DIRECTIVE
In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac
compression, endotracheal intubation and other advanced airway management, artificial ventilation,
defibrillation, administration of advanced cardiac life support drugs and related emergency medical
procedures.
Patient's Printed Name: _________________________________________
Patient’s Signature: _________________________________________Date: _______________
*If I am unable to communicate my wishes, and I have designated a Health Care Power of
Attorney, my elected Health Care agent shall sign:
Health Care Power of Attorney Printed Name: _________________________________________
Health Care Power of Attorney Signature: ___________________________________________
PROVIDE THE FOLLOWING INFORMATION OR ATTACH A RECENT PHOTO:
Date of Birth_____________
Sex____________________
Race___________________
Eye Color _______________
Hair Color ______________
INFORMATION ABOUT MY DOCTOR AND HOSPICE (if I am in Hospice):
Physician: Telephone: _________________
Hospice Program, if applicable (name):
SIGNATURE OF DOCTOR OR OTHER HEALTH CARE PROVIDER
I have explained this form and its consequences to the signer and obtained assurance that the
signer understands that death may result from any refused care listed above.
Signature of a Licensed Health Care Provider: _________________________________________
Date: _________________
SIGNATURE OF WITNESS OR NOTARY (NOT BOTH)
I was present when this form was signed (or marked). The patient then appeared to be of sound
mind and free from duress.
Witness Signature: Date: _______________
NO
TORIAL JURAT:
STATE OF ARIZONA ) ss
COUNTY OF ______________)
________________________________________________
Patient’s Name/Health Care Power of Attorney Name
Subscribed and sworn (or affirmed) before me this ______________ day of __________, 20 ______
Notary Public Signature: ____________________________My Commission Expires: ____________
Office of Arizona Attorney General,
Kris Mayes