Arizona Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with Arizona Revised Statutes § 36-3201 et seq. It allows you to appoint an agent to make healthcare decisions on your behalf when you are unable to do so.
Please fill in the blanks with your information as indicated.
Principal Information:
Name: ________________________________________
Address: ______________________________________
City: ________________________________________
State: Arizona
Zip Code: ___________________________________
Date of Birth: ________________________________
Agent Information:
Name: ________________________________________
Address: ______________________________________
City: ________________________________________
State: ______________________________________
Zip Code: ___________________________________
Phone Number: ________________________________
Alternate Agent Information (optional):
Name: ________________________________________
Address: ______________________________________
City: ________________________________________
State: ______________________________________
Zip Code: ___________________________________
Phone Number: ________________________________
Grant of Authority:
I, the undersigned, hereby appoint my agent to make healthcare decisions on my behalf in accordance with Arizona law. This authority includes, but is not limited to:
- Making decisions about medical treatment and procedures.
- Accessing my medical records and information.
- Choosing healthcare providers and facilities.
- Making decisions regarding life-sustaining treatment.
Effective Date:
This Medical Power of Attorney becomes effective upon my incapacity as determined by a qualified healthcare professional.
Signature:
_________________________________________
Principal's Signature
Date: _____________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to you or your agent.
- Witness 1 Name: ____________________________
- Witness 1 Signature: ______________________
- Witness 1 Date: __________________________
- Witness 2 Name: ____________________________
- Witness 2 Signature: ______________________
- Witness 2 Date: __________________________
Notarization (optional):
State of Arizona
County of _________________________________
Subscribed and sworn before me on this ______ day of __________, 20__.
_________________________________________
Notary Public
My Commission Expires: __________________