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Arizona _____. (date) I have agreed to comply with the provisions of this directive. ___________________________ Signature of Physician Page 4 of 4 document and have discussed with _________ any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with the principal occurred on ___________tive. If you do speak with your physician it is a good idea to ask your physician to complete this affidavit and keep a copy for his file.) I, Dr. ________________________ have reviewed this guidance ion Expires: _______________ Page 3 of 4 Physician Affidavit (Optional) (Before initialing any choices above you may wish to ask questions of your physician regarding a particular treatment alternae intends to adopt the Health Care Power of Attorney at this time. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. Notary Public signature: ______________________________ My CommissCare Power of Attorney is physically unable to sign or mark this document, I verify that he/she directly indicated to me that this Health Care Power of Attorney expresses his/her wishes and that he/shved in providing health care to the person signing. I am not entitled to any part of his/her estate under a will now existing or by operation of law. In the event the person acknowledging this Health n expressed.. I further declare I am not related to the person signing above by blood, marriage or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly invol, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the foregoing Health Care Power of Attorney and acknowledged that they executed the same for the purpose thereiARIZONA County of ______ ) ) ss. ) On this the ____ day of ___________, ____, PRINCIPAL and _____________________ and ____________________ personally appeared before me, the undersigned Notary Publicature: __________________________________________ Witness Address: __________________________________________ NOTE: A Notary Public is only required if no witness signed above Notarization STATE OF the GRANTOR dated and signed this health care power of attorney. Witness Signature: __________________________________________ Witness Address: __________________________________________ Witness Signh care power of attorney must be notarized or witnessed Witness Statement Each witness who signs this health care power of attorney declares under penalty of perjury that such witness was present when____________________________________________ Address of AGENT: ___________________________________________ Telephone of AGENT: __________________________________________ Page 2 of 4 NOTE: This healtence of my being able to give health care directions. Signature of Principal: __________________________________________ Date: _______________________________________________________ Time: ___________r therapeutic purposes only. 4. Other or Additional Statements of Desires I have _____ I have not _____ attached additional special provisions or limitations to this document to be honored in the abs listed: ____________________________________________ _____________________________________________________________________________ for (check one): o o Any legally authorized purpose. Transplant o following individual or institution: _____________________________ _______ Pursuant to Arizona law, I hereby give, effective on my death: o o Any needed organ or parts. The following part or organsnot want to make an organ or tissue donation and I do not want my agent or family to do so. _______ I have already signed a written agreement or donor card regarding organ and tissue donation with theinitial any of the statements. If you do not check any of the statements, your agent and your family will have the authority to make a gift of all or part of your body under Arizona law. _______ I do ation elections you make in this health care power of attorney survive your death.) If any of the statements below reflects your desire, initial on the line next to that statement. You do not have to or state that you do not want to make a gift. Page 1 of 4 If you do not complete this section, your agent will have the authority to make a gift of a part of your body pursuant to law. Note: The donnce. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental evaluation or research or for the advancement of medical or dental scie. _______ 2. I consent to an autopsy. _______ 3. My agent may give consent to or refuse an autopsy. 3. Organ Donation (Optional) (Under Arizona law, you may make a gift of all or part of your body to have given notice of its revocation. 2. Autopsy (under Arizona law an autopsy may be required) (Optional) If you wish to do so, reflect your desires below: _______ 1. I do not consent to an autopsy section 363251, Arizona Revised Statutes. This health care directive is made under section 36-3221, Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom Icisions or after my death. My agent is directed to implement those choices I have initialed in the living will. I have _____ I have not _____ completed a prehospital medical care directive pursuant to____ completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care deives as if I were alive, competent and acting for myself. If my agent is unwilling or unable to serve or continue to serve, I hereby appoint ____________________ as my agent. I have _____ I have not _ing any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and personal representatll medical, surgical, hospital and related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent's actions under this power dur, __________________________, as principal, designate _________________ as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to any part of the principal's estate by will or by operation of law at the time that the power of attorney is executed. STATE OF ARIZONA HEALTH CARE POWER OF ATTORNEY 1. Health Care Power of Attorney Iattorney is executed. D. If a health care power of attorney is witnessed by only one person, that person may not be related to the principal by blood, marriage or adoption and may not be entitled to awing: 1. A person designated to make medical decisions on the principal's behalf. 2. A person directly involved with the provision of health care to the principal at the time the health care power of otary or witness that the power of attorney expressed the person's wishes and that the person intended to adopt the power of attorney at that time. C. A notary or witness shall not be any of the folloer of attorney. B. If a person is physically unable to sign or mark a health care power of attorney, the notary or each witness shall verify on the document that the person directly indicated to the nr marked the health care power of attorney, except as provided under subsection B, and that the person appeared to be of sound mind and free from duress at the time of execution of the health care powthe subject of the health care power of attorney. 3. Is notarized or is witnessed in writing by at least one adult who affirms that the notary or witness was present when the person dated and signed oontains language that clearly indicates that the person intends to create a health care power of attorney. 2. Except as provided under subsection B, is dated and signed or marked by the person who is dult individual or other adult individuals to make health care decisions on that person's behalf by executing a written health care power of attorney that meets all of the following requirements: 1. CInformation Arizona Health Care Power of Attorney Arizona Revised Statutes 36-3221. Health care power of attorney; scope; requirements; limitations A. A person who is an adult may designate another a Arizona