ARIZONA HEALTH CARE POWER OF ATTORNEY
(Arizona Revised Statutes (“A.R.S.”) Title 36, Chapter 32 Compliant)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Designation & Acceptance of Agent
3.2 Scope of Authority
3.3 End-of-Life Decisions
3.4 HIPAA Authorization
3.5 Nomination of Guardian / Conservator (Optional)
3.6 Organ & Anatomical Gifts (Optional) - Representations & Warranties
- Covenants & Restrictions of Agent
- Revocation, Resignation & Successor Appointment
- Risk Allocation
- Dispute Resolution & Governing Law
- General Provisions
- Execution Block (Signature, Witnesses/Notary)
1. DOCUMENT HEADER
1.1 Title & Parties.
This Health Care Power of Attorney (“Power” or “Agreement”) is made on [EFFECTIVE DATE] (“Effective Date”) by [PRINCIPAL FULL LEGAL NAME], residing at [PRINCIPAL ADDRESS] (“Principal”), in favor of the individual designated herein as Agent.
1.2 Recitals.
A. Principal desires, pursuant to A.R.S. §§ 36-3221 et seq., to appoint an agent to make health care decisions in the event Principal is unable to do so.
B. Principal is of sound mind and acting voluntarily.
C. Consideration is acknowledged by mutual promises herein.
1.3 Governing Jurisdiction.
This Power shall be governed by the health-care-directive laws of the State of Arizona.
2. DEFINITIONS
For purposes of this Power, capitalized terms have the meanings set forth below:
“Advance Directive” – a written instruction, recognized under A.R.S. Title 36, Chapter 32, concerning the making of health-care decisions for the Principal.
“Agent” – the person(s) designated in Section 3.1 to make health-care decisions for the Principal.
“Good Faith” – honesty in fact in the conduct or transaction concerned.
“Health-Care Decision” – any consent, refusal, withdrawal, or selection of treatment, service, or procedure to maintain, diagnose, or treat Principal’s physical or mental condition.
“HIPAA” – the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, including 45 C.F.R. § 164.508.
“Permanent Vegetative State” – a medical condition of complete and irreversible unconsciousness with no hope of recovery, as certified by two licensed physicians.
3. OPERATIVE PROVISIONS
3.1 Designation & Acceptance of Agent
a. Primary Agent: [PRIMARY AGENT NAME], residing at [ADDRESS], telephone [PHONE], email [EMAIL].
b. First Alternate Agent: [ALTERNATE AGENT 1 NAME] (optional).
c. Second Alternate Agent: [ALTERNATE AGENT 2 NAME] (optional).
d. Each Alternate shall serve only if all prior-named Agents are unwilling, unable, or ineligible to serve.
e. Agent accepts the appointment by signing in the Execution Block.
[// GUIDANCE: Advise clients to obtain Agents’ written acceptance to avoid later challenges.]
3.2 Scope of Authority
a. Subject to Section 3.3 and applicable law, Agent is authorized to make any and all Health-Care Decisions the Principal could make if able, including but not limited to:
i. Selecting or discharging health-care providers and facilities;
ii. Approving or refusing tests, drugs, surgery, or other interventions;
iii. Giving informed consent, waiver, or release of liability;
iv. Accessing medical records to the same extent as Principal;
v. Authorizing admission to or discharge from hospitals, skilled nursing, hospice, or home-health services;
vi. Making decisions regarding pain relief, palliative care, and do-not-resuscitate (“DNR”) orders.
b. Agent’s authority commences upon determination, by the attending physician or qualified health-care provider, that Principal lacks capacity, and continues until revoked pursuant to Section 6.
3.3 End-of-Life Decisions
a. Life-Sustaining Treatment. If Principal has a terminal condition or is in a Permanent Vegetative State, Agent [SHALL / SHALL NOT] authorize life-sustaining treatment that merely prolongs the dying process.
b. Artificial Nutrition & Hydration (“ANH”). Agent [MAY / MAY NOT] withhold or withdraw ANH when:
i. The burdens outweigh expected benefits in the judgment of Agent and attending physician; or
ii. Provision of ANH conflicts with Principal’s documented wishes.
c. Palliative Care Preference. Principal desires comfort-focused care, even if such care may hasten death.
d. Pregnancy Exception (if applicable). If Principal is pregnant, Agent’s authority is subject to A.R.S. § 36-3203.
[// GUIDANCE: Arizona does not permit abortion decisions via POA; ensure compliance with current statutes.]
3.4 HIPAA Authorization
Pursuant to 45 C.F.R. § 164.508, Principal authorizes any covered entity to disclose to Agent all protected health information (“PHI”) necessary to exercise the powers herein. This authorization:
a. Is effective upon execution and survives Principal’s incapacity;
b. Expires [X YEARS] after Principal’s death unless revoked earlier; and
c. Includes authority to sign any further documents required by providers.
3.5 Nomination of Guardian / Conservator (Optional)
Should a court determine a guardian or conservator is necessary, Principal nominates the then-serving Agent. The court shall give priority to this nomination under A.R.S. § 14-5311.
3.6 Organ & Anatomical Gifts (Optional)
Principal [DOES / DOES NOT] authorize the Agent to consent to donation of organs or tissues for transplantation, therapy, research, or education pursuant to A.R.S. § 36-844.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal represents that:
a. Principal is at least 18 years old, of sound mind, and not acting under duress.
b. Execution of this Power revokes all prior health-care powers of attorney executed by Principal.
4.2 Agent represents, upon acceptance, that Agent:
a. Is not disqualified under A.R.S. § 36-3221(B) (e.g., not the Principal’s paid caregiver);
b. Shall act in Good Faith and in accordance with Principal’s known wishes or, if unknown, Principal’s best interests.
5. COVENANTS & RESTRICTIONS OF AGENT
a. Substituted Judgment. Agent shall follow Principal’s expressed wishes to the extent known.
b. Record-Keeping. Upon request, Agent shall provide interested persons a written accounting of actions taken.
c. No Compensation. Agent shall serve without compensation except reimbursement of reasonable out-of-pocket expenses.
d. Conflicts of Interest. Agent shall avoid any decision presenting a conflict between Agent’s personal interests and those of Principal.
6. REVOCATION, RESIGNATION & SUCCESSOR APPOINTMENT
6.1 Revocation by Principal. Principal may revoke this Power at any time by:
a. Written notice to Agent or health-care provider;
b. Orally expressing intent to revoke in presence of a witness; or
c. Executing a subsequent valid health-care power of attorney.
6.2 Resignation of Agent. Agent may resign by written notice to:
a. Principal (if competent); and
b. Successor Agent(s) and attending physician.
6.3 Removal for Cause. An interested person may petition the Superior Court of Arizona, Probate Division, to remove an Agent for misconduct or incapacity.
7. RISK ALLOCATION
7.1 Indemnification. Principal shall indemnify and hold harmless Agent from any liability, claim, or expense, including reasonable attorneys’ fees, incurred as a result of acts performed in Good Faith under this Power.
7.2 Limitation of Liability. No Agent shall be liable for exercising or failing to exercise powers in Good Faith and in accordance with A.R.S. § 36-3224.
7.3 Reliance by Third Parties. Any third party may rely on the validity of this Power and on the representations of the then-serving Agent without further inquiry.
8. DISPUTE RESOLUTION & GOVERNING LAW
8.1 Governing Law. This Power and any dispute arising hereunder shall be governed by the laws of the State of Arizona.
8.2 Forum Selection. Exclusive jurisdiction and venue shall lie in the Probate Division of the Superior Court of Arizona in [COUNTY] County.
8.3 Injunctive Relief. The court may enter injunctive or declaratory relief to enforce or interpret this Power consistent with A.R.S. Title 36, Chapter 32. Arbitration and jury trial waivers are intentionally omitted.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers. Any amendment must be executed with the same formalities as this Power. No waiver shall be effective unless in writing and signed by the waiving party.
9.2 Severability. If any provision is held invalid, the remaining provisions shall continue in full force and effect.
9.3 Entire Agreement. This document constitutes the entire health-care power of attorney of Principal and supersedes all prior inconsistent directives.
9.4 Counterparts; Electronic Signatures. This Power may be executed in counterparts, each of which shall be deemed an original. Signatures delivered via electronic means shall be deemed original for all purposes pursuant to A.R.S. § 44-7031.
9.5 Copies. Photographic or electronically transmitted copies shall have the same force as originals.
10. EXECUTION BLOCK
PRINCIPAL
I, [PRINCIPAL NAME], sign my name to this Health Care Power of Attorney on the date below and, being first duly sworn, do declare that I sign it willingly and that I execute it as my free and voluntary act.
Signature: ____
Printed Name: ____
Date: ________
AGENT(S) ACCEPTANCE
I, the undersigned Agent, accept the appointment and agree to act in accordance with the foregoing Power and Arizona law.
| Role | Name | Signature | Date |
|---|---|---|---|
| Primary Agent | [NAME] | ______ | ____ |
| 1st Alternate | [NAME] | ______ | ____ |
| 2nd Alternate | [NAME] | ______ | ____ |
OPTION A – NOTARIZATION
State of Arizona )
County of [COUNTY] ) ss.
Subscribed and sworn before me this ___ day of ____, 20__, by [PRINCIPAL NAME].
Notary Public ____
My Commission Expires: _______
OPTION B – TWO WITNESSES
(Use witnesses only if not notarized; witnesses must meet A.R.S. § 36-3221 requirements.)
-
Witness #1 Signature ___ Date _
Printed Name ___
Address ____ -
Witness #2 Signature ___ Date _
Printed Name ___
Address ____
[// GUIDANCE: Witnesses may not be related by blood, marriage, or adoption, entitled to any portion of the Principal’s estate, or directly involved in providing health-care services to the Principal.]
END OF DOCUMENT