Healthcare Power of Attorney - Arkansas

ARKANSAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Important Information

This document appoints an agent to make health-care decisions and permits
individual health-care instructions. It does not grant authority over money or
property. A separate Arkansas advance directive or living will may provide a
more detailed treatment plan.

You retain the right to make your own health-care decisions while you have
capacity. Discuss this document with your agent, health-care providers, family,
and an Arkansas attorney. Give copies to the people and institutions that may
need it.

1. Principal

Name: [FULL LEGAL NAME]

Date of birth: [__/__/____]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

2. Appointment of Agent

I appoint the following person as my agent for health-care decisions:

Name: [PRIMARY AGENT NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

First Alternate Agent

If my primary agent is unwilling, unable, or not reasonably available to act,
I appoint:

Name: [FIRST ALTERNATE NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

Second Alternate Agent

If neither person named above is willing, able, or reasonably available to
act, I appoint:

Name: [SECOND ALTERNATE NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

3. Grant of Authority

Except as limited below, my agent may make any health-care decision that I
could make if I had capacity.

My agent must follow my individual instructions and other wishes to the extent
known. If my instructions and wishes are not known, my agent must decide
according to my best interest and consider my personal values to the extent
known.

Limitations on my agent's authority:

[DESCRIBE OR WRITE "NONE"]

4. When My Agent's Authority Begins

Select one. If neither choice is selected, the default rule in the first choice
applies.

☐ When I lack capacity. My agent's authority begins only when a licensed
physician determines that I lack capacity and ends when a licensed physician
determines that I have recovered capacity.

☐ Immediately. My agent's authority begins when I sign this document. I
retain my right to make my own health-care decisions while I have capacity, and
my own decision controls.

5. Health-Care Information

When my agent is authorized to make health-care decisions for me, my agent has
the same rights I would have to request, receive, examine, copy, and consent to
the disclosure of medical and other health-care information.

6. Individual Instructions and Limitations

My agent must follow these instructions and limitations:

[DESCRIBE TREATMENT WISHES, RELIGIOUS OR PERSONAL DIRECTIONS, PROVIDER OR
FACILITY PREFERENCES, OR WRITE "NONE"]

7. Nomination of Guardian

If a court appoints a guardian for me, I nominate my primary agent. If that
person cannot serve, I nominate my alternate agents in the order listed.

Different nomination: [NAME AND CONTACT INFORMATION OR "NONE"]

8. Revocation, Former Spouse, and Copies

While I have capacity, I may revoke all or part of this document at any time
and in any manner that communicates my intent to revoke. A person informed of
my revocation should promptly tell my supervising health-care provider and any
health-care institution where I am receiving care.

Unless this document or a qualifying decree provides otherwise, annulment,
divorce, dissolution of marriage, or legal separation revokes an earlier
designation of my spouse as agent. A later advance directive revokes an earlier
directive to the extent they conflict.

A copy of this written document or its revocation has the same effect as the
original.

9. Principal's Signature

I understand this document and sign it voluntarily.

Signature: ____________________________________

Printed name: [FULL LEGAL NAME]

Date: [__/__/____]

Address: [ADDRESS]

10. Choose One Execution Method

Complete either Method A or Method B. Do not leave both methods incomplete.

Method A — Two Competent Adult Witnesses

Neither witness may be an agent named in this document. At least one witness
must be unrelated to the principal by blood, marriage, or adoption and must not
be entitled to any part of the principal's estate under an existing will or
codicil or by operation of law.

Witness 1

I am a competent adult, I am not an agent named in this document, and I
witnessed the principal sign this document.

Signature: ____________________________________

Printed name: [WITNESS 1 NAME]

Address: [ADDRESS]

Date: [__/__/____]

Witness 2

I am a competent adult, I am not an agent named in this document, I am not
related to the principal by blood, marriage, or adoption, and I would not be
entitled to any part of the principal's estate under an existing will or
codicil or by operation of law. I witnessed the principal sign this document
in my presence.

Signature: ____________________________________

Printed name: [WITNESS 2 NAME]

Address: [ADDRESS]

Date: [__/__/____]

Method B — Notary Acknowledgment

State of Arkansas

County of [COUNTY]

The person who signed this instrument is personally known to me or proved to
me through satisfactory evidence to be the person named above as the
principal. The principal personally appeared before me and signed this
instrument or acknowledged the signature as the principal's own.

Notary signature: ____________________________________

Printed name: [NOTARY NAME]

Date: [__/__/____]

My commission expires: [__/__/____]

Notary seal:

Sources and References

• Arkansas Act 1264 of 2013 — Arkansas Healthcare Decisions Act
• Arkansas Act 974 of 2017 — current health-care-POA execution, effectiveness, and revocation rules
• Arkansas Department of Health — Healthcare Decision Forms
• Arkansas Department of Health — Appointment of Health Care Agent