ARKANSAS DURABLE HEALTHCARE POWER OF ATTORNEY

(Including End-of-Life Directive & HIPAA Authorization)

[// GUIDANCE: This template is designed to comply with Arkansas statutory requirements for a durable power of attorney for health care, living-will–style end-of-life instructions, and HIPAA authorization. Practitioners should review all bracketed options with the Principal, confirm witness/notary mechanics under current Arkansas law, and tailor special instructions as needed.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Grant of Authority
   3.2 Scope of Authority
   3.3 HIPAA Authorization
   3.4 End-of-Life Instructions
   3.5 Appointment of Successor Agents
   3.6 Guardianship Nomination
   3.7 Anatomical Gifts (Optional)
   3.8 Special Instructions / Limitations
4. Representations & Warranties
5. Covenants & Restrictions (Agent Duties)
6. Revocation, Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title. Arkansas Durable Healthcare Power of Attorney, End-of-Life Directive, and HIPAA Authorization (“Instrument”).
1.2 Parties.
(a) “Principal”: [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS].
(b) “Agent”: [PRIMARY AGENT FULL LEGAL NAME], residing at [ADDRESS].
(c) “Alternate Agent(s)” (in order of priority):
 1. [ALTERNATE AGENT #1 NAME & ADDRESS]
 2. [ALTERNATE AGENT #2 NAME & ADDRESS]
1.3 Effective Date. This Instrument is effective on the date executed below and shall remain durable notwithstanding the Principal’s subsequent incapacity, except as revoked pursuant to Section 6.
1.4 Governing Law. This Instrument shall be governed by, and construed in accordance with, the healthcare decision-making statutes and public-policy principles of the State of Arkansas (“Governing Law”).
1.5 Consideration. The parties acknowledge this Instrument is executed as an agency appointment and not for contractual consideration.

2. DEFINITIONS

For ease of reference, capitalized terms have the meanings set forth below. Terms defined in the singular include the plural and vice-versa.

“Advance Directive” – Collectively, the healthcare instructions set forth in this Instrument, including End-of-Life Instructions in § 3.4.
“Agent” – The individual(s) designated in § 1.2 to make Healthcare Decisions on the Principal’s behalf.
“Good Faith” – Honesty in fact and reasonable belief that the action is in the Principal’s best interests.
“Health Care Provider” – Any person or facility licensed, certified, or otherwise authorized by Arkansas law to provide healthcare or services.
“Healthcare Decision” – Any consent, refusal, withdrawal, or request concerning diagnosis, treatment, medication, surgery, or any procedure to affect the Principal’s physical or mental condition.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d et seq., and its implementing regulations.
“Incapacitated” – As determined by the attending physician, the Principal lacks the ability to understand relevant information or communicate informed decisions.
“Life-Sustaining Treatment” – Mechanical ventilation, dialysis, cardiopulmonary resuscitation (“CPR”), artificial nutrition/hydration, and other treatments that serve only to prolong the dying process.

3. OPERATIVE PROVISIONS

3.1 Grant of Authority

The Principal hereby appoints the Agent to make all Healthcare Decisions, including mental-health treatment decisions, for the Principal whenever the Principal is Incapacitated, subject to any limitations in this Instrument. The authority is intended to be as broad as Arkansas law allows.

3.2 Scope of Authority

Without limiting the general grant in § 3.1, the Agent may:
a. Provide informed consent to, refuse, or withdraw any healthcare, including Life-Sustaining Treatment;
b. Admit or discharge the Principal from any hospital, nursing home, residential care, hospice, or similar facility;
c. Contract for any healthcare‐related service or facility (the Principal shall remain responsible for payment);
d. Access, review, and disclose medical records;
e. Employ or discharge healthcare personnel;
f. Authorize pain relief, including controlled substances;
g. Make decisions regarding organ donation and autopsy, subject to § 3.7;
h. Take any other action necessary to implement this Instrument.

3.3 HIPAA Authorization

The Principal authorizes any Health Care Provider, insurer, or other covered entity to disclose to the Agent protected health information (“PHI”) relating to the Principal, consistent with 45 C.F.R. § 164.502 and § 164.508. This authorization is effective immediately and survives the Principal’s death to the extent PHI is required to carry out post-death healthcare decisions or anatomical gifts.

[// GUIDANCE: Some Arkansas facilities prefer a stand-alone HIPAA release. If needed, duplicate this section in a separate document for operational convenience.]

3.4 End-of-Life Instructions

The Principal makes the following election concerning Life-Sustaining Treatment when (i) the Principal has an incurable and irreversible condition that will result in death within a relatively short time or (ii) is permanently unconscious:

☐ (A) WITHHOLD OR WITHDRAW Life-Sustaining Treatment and allow natural death to occur.
☐ (B) PROVIDE Life-Sustaining Treatment in an effort to sustain life as long as medically possible.
☐ (C) FOLLOW Agent’s Determination after consultation with treating physicians.

Artificial Nutrition & Hydration (Choose one):
☐ 1. WITHHOLD/WITHDRAW even if death results.
☐ 2. PROVIDE if needed for comfort or recovery.
☐ 3. FOLLOW Agent’s Determination.

[// GUIDANCE: Arkansas law requires the Principal’s explicit initialing of chosen options. Insert signature lines or initial boxes adjacent to selections during finalization.]

3.5 Appointment of Successor Agents

If the Primary Agent is unavailable, unwilling, or incapable of acting, authority passes in the order listed in § 1.2(c). Each successor Agent shall have the same powers and duties as the Primary Agent, subject to any limitations herein.

3.6 Guardianship Nomination

If a court determines a guardian is necessary, the Principal nominates the acting Agent as guardian of the person. The court shall give this nomination priority consistent with Arkansas probate procedure.

3.7 Anatomical Gifts (Optional)

☐ The Principal authorizes the Agent to consent to the donation of [ALL ORGANS / SPECIFIC ORGANS / TISSUES] for transplantation, therapy, research, or education.
☐ No anatomical gifts are authorized.

3.8 Special Instructions / Limitations

[INSERT ANY LIMITATIONS, RELIGIOUS CONSIDERATIONS, OR EXPIRATION DATE IF DESIRED.]

4. REPRESENTATIONS & WARRANTIES

4.1 Principal Representation. The Principal is of sound mind, at least 18 years of age, and executing this Instrument voluntarily.
4.2 Agent Representation. By signing the Acceptance below, each Agent represents (i) willingness to serve, (ii) absence of disqualifying conflict of interest, and (iii) commitment to act in Good Faith.

5. COVENANTS & RESTRICTIONS (Agent Duties)

5.1 Fiduciary Duty. The Agent shall act in Good Faith, consistent with the Principal’s known wishes and best interests.
5.2 Consultation. The Agent shall consult with healthcare professionals and, when feasible, family or spiritual advisors.
5.3 Record-Keeping. Upon request of a treating facility or court, the Agent shall provide a summary of decisions made.
5.4 No Delegation. The Agent may not delegate decision-making authority except to a duly-appointed successor Agent under § 3.5.

6. REVOCATION, DEFAULT & REMEDIES

6.1 Revocation by Principal. The Principal may revoke this Instrument at any time by (i) written revocation, (ii) oral statement in the presence of a Health Care Provider, or (iii) execution of a subsequent healthcare power of attorney.
6.2 Removal for Cause. Any interested person may petition the state probate court to remove an Agent who (i) acts outside authority, (ii) is unavailable, or (iii) fails to act in Good Faith.
6.3 Reliance Protection. A Health Care Provider acting in reliance on a copy of this Instrument may presume it is valid unless given actual notice of revocation.

7. RISK ALLOCATION

7.1 Indemnification. The Principal agrees to indemnify and hold harmless the Agent from any claim, cost, or liability arising from Good-Faith exercise of authority hereunder, except for willful misconduct or gross negligence.
7.2 Limitation of Liability. In no event shall the Agent be liable for monetary damages exceeding direct losses proximately caused by the Agent’s willful misconduct or gross negligence.
7.3 Insurance. [OPTIONAL: State whether the Principal maintains liability insurance for the Agent’s benefit.]

8. DISPUTE RESOLUTION

8.1 Governing Law. See § 1.4.
8.2 Forum Selection. Exclusive venue for any proceeding arising under or relating to this Instrument shall be the appropriate Arkansas state probate court.
8.3 Arbitration. Arbitration is not available for disputes under this Instrument.
8.4 Jury Waiver. Not applicable.
8.5 Injunctive Relief. Nothing limits the court’s equitable power to enforce healthcare directives or restrain unauthorized conduct.

9. GENERAL PROVISIONS

9.1 Amendments. Must be in writing, signed by the Principal, and witnessed/notarized with the same formalities as this Instrument.
9.2 Assignment. The powers herein are personal and may not be assigned.
9.3 Successors & Assigns. Binding on the Principal’s heirs, executors, administrators, and permitted Agents.
9.4 Severability. If any provision is held invalid, remaining provisions remain enforceable.
9.5 Entire Agreement. This Instrument constitutes the Principal’s complete healthcare directive and supersedes all prior inconsistent directives.
9.6 Counterparts & Electronic Signatures. This Instrument may be executed in counterparts and by electronic signature to the extent permitted by Arkansas law.

10. EXECUTION BLOCK

10.1 Principal’s Signature

I, [PRINCIPAL NAME], sign my name to this Arkansas Durable Healthcare Power of Attorney on [DATE], at [CITY], Arkansas.

[PRINCIPAL NAME], Principal

10.2 Agent’s Acceptance

I, [AGENT NAME], accept appointment as Agent and agree to act in accordance with this Instrument and Arkansas law.

[AGENT NAME], Agent Date: ___

(Attach identical acceptance blocks for each Alternate Agent.)

10.3 Witness Attestation

We declare that the Principal is personally known to us, appears to be of sound mind, and signed or acknowledged this Instrument in our presence. We are each at least 18 years old, not related by blood or marriage, not entitled to any portion of the Principal’s estate, and not directly responsible for the Principal’s healthcare.

Witness #1: ____ Date: _
Name & Address: _________

Witness #2: ____ Date: _
Name & Address: _________

[// GUIDANCE: Arkansas practice generally requires two qualified witnesses OR a notary. When in doubt, obtain both.]

10.4 Notary Acknowledgment

State of Arkansas )
County of ____ ) SS.

On this ___ day of ___, 20_, before me, a Notary Public duly commissioned, personally appeared [PRINCIPAL NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this Instrument, and acknowledged that he/she executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

Notary Public
My Commission Expires: ___

[END OF DOCUMENT]