Arizona Medical Power of Attorney
This Arizona Medical Power of Attorney allows you to appoint someone to make medical decisions on your behalf if you become unable to do so. This document is governed by Arizona Revised Statutes, Title 36, Chapter 32.
Principal Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Alternate Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Effective Date: This Medical Power of Attorney becomes effective when I am determined to be unable to make my own medical decisions by a licensed physician.
Agent's Authority: My agent shall have the authority to make decisions regarding my medical care, including:
- Choosing healthcare providers.
- Accessing my medical records.
- Consenting to or refusing medical treatment.
- Making decisions about life-sustaining treatments.
Signature:
I, ___________________________ (Principal's Name), hereby appoint the above-named agent to act on my behalf in accordance with this Medical Power of Attorney.
Principal's Signature: ___________________________
Date: ___________________________
Witness Signature 1: ___________________________
Date: ___________________________
Witness Signature 2: ___________________________
Date: ___________________________
Notary Public:
State of Arizona
County of ___________________________
Subscribed and sworn before me on this _____ day of ____________, 20__.
Notary Public Signature: ___________________________
My Commission Expires: ___________________________