Healthcare Power of Attorney - Arizona

ARIZONA HEALTH CARE POWER OF ATTORNEY

Important Information

This document lets an adult appoint an adult agent to make future health-care
decisions when the principal cannot make or communicate those decisions. It
does not itself provide detailed end-of-life or mental-health instructions;
Arizona supplies separate Living Will and Mental Health Care Power of Attorney
forms for those purposes.

Discuss this document with your agent, health-care providers, family, and an
Arizona 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 adult to make health-care decisions for me when I
cannot make or communicate my own health-care decisions:

Name: [PRIMARY AGENT NAME]

Address: [ADDRESS]

Home telephone: [TELEPHONE]

Mobile telephone: [TELEPHONE]

Email: [EMAIL]

First Alternate Agent

If my primary agent is unavailable, unwilling, or unable to act, I appoint:

Name: [FIRST ALTERNATE NAME]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

Second Alternate Agent

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

Name: [SECOND ALTERNATE NAME]

Address: [ADDRESS]

Telephone: [TELEPHONE]

Email: [EMAIL]

3. Agent's Authority

I authorize my agent to make health-care decisions for me when I cannot make
or communicate them. My agent may make all such decisions except those I
expressly withhold below and should follow my known wishes.

Decisions I do not authorize my agent to make:

[DESCRIBE OR WRITE "NONE"]

I authorize my agent to have access to my protected health-care information
and medical records as needed to make health-care decisions for me.

4. Autopsy Choice

Initial one:

[____] I do not consent to a voluntary autopsy unless required by law.

[____] I consent to a voluntary autopsy.

[____] My agent may consent to or refuse a voluntary autopsy.

5. Organ and Tissue Donation

Select one:

☐ I donate my organs, tissues, and eyes for transplant and therapy and for
research and education, subject to these limits: [DESCRIBE OR WRITE "NONE"]

☐ I have already registered as a donor and want that decision followed.

☐ I want my agent to decide whether to authorize organ or tissue donation.

☐ I do not want to make an organ or tissue donation, and I do not authorize
another person to make one for me.

6. Funeral and Disposition Instructions

Initial or complete any applicable choice:

[____] My agent will make my funeral and disposition decisions.

[____] I direct burial at: [LOCATION]

[____] I direct cremation, with my ashes to be: [INSTRUCTIONS]

Other instructions: [DESCRIBE OR WRITE "NONE"]

7. Related Arizona Forms

Initial as applicable:

[____] I have signed and attached an Arizona Living Will.

[____] I have signed and attached a separate Mental Health Care Power of
Attorney.

[____] I have signed and attached a POLST medical order.

[____] I and my physician or other licensed health-care provider have
signed an Arizona Prehospital Medical Care Directive on orange paper.

8. Revocation

I retain the right to revoke all or part of this document or disqualify an
agent by a written revocation, oral notice to my agent or a health-care
provider, a new health-care directive, or another act demonstrating my specific
intent to revoke or disqualify.

9. Principal's Signature

Do not sign until the qualified witness or qualified notary is present.

Signature or mark: ____________________________________

Printed name: [FULL LEGAL NAME]

Date: [__/__/____]

If I am physically unable to sign or mark, I directly indicate to the witness
or notary that this document expresses my wishes and that I intend to adopt it
now.

Witness/notary verification signature, if applicable:
____________________________________

Printed name: [NAME]

Date: [__/__/____]

10. Choose One Verification Method

Complete either Method A or Method B, not both. The witness or notary must be
an adult, may not be an agent named in this document, and may not be directly
involved in providing my health care when I sign. The current Attorney General
form also excludes a person related to me by blood, adoption, or marriage or
entitled to part of my estate.

Method A — One Adult Witness

I was present when the principal signed or marked this document. The principal
appeared to be of sound mind and free from duress. I am qualified to serve as a
witness under the restrictions above.

Witness signature: ____________________________________

Printed name: [WITNESS NAME]

Address: [ADDRESS]

Date: [__/__/____]

Method B — Notarial Jurat

State of Arizona

County of [COUNTY]

Subscribed and sworn or affirmed before me by [PRINCIPAL NAME] on
[__/__/____].

Notary signature: ____________________________________

Printed name: [NOTARY NAME]

My commission expires: [__/__/____]

Notary seal:

Sources and References

• A.R.S. § 36-3202 — revocation and disqualification
• A.R.S. § 36-3221 — health-care POA and execution
• Arizona Attorney General — Life Care Planning forms
• Arizona Attorney General — Health Care Power of Attorney, updated August 2026