Arizona Medical Power of Attorney Template
This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so. It complies with Arizona state laws regarding medical powers of attorney.
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Durable Medical Power of Attorney:
I, _______________________________, hereby appoint _______________________________ as my agent to make health care decisions on my behalf if I am unable to make those decisions myself.
Agent's Authority:
The agent shall have the authority to make all health care decisions for me, including but not limited to:
- Choosing health care providers.
- Accepting or refusing medical treatment.
- Accessing my medical records.
- Making decisions about life-sustaining treatment.
Effective Date:
This Medical Power of Attorney becomes effective when my physician determines that I am unable to make my own health care decisions.
Revocation:
I understand that I can revoke this Medical Power of Attorney at any time as long as I am competent to do so.
Signatures:
Signed this ____ day of __________, 20__.
_______________________________
Signature of Principal
Witnesses:
Two witnesses must sign below. Witnesses cannot be the agent or related to the principal.
- _______________________________
Signature of Witness 1
- _______________________________
Signature of Witness 2
Notarization:
State of Arizona
County of ____________________________
Subscribed and sworn before me this ____ day of __________, 20__.
_______________________________
Notary Public