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Arkansas : ___________________________________ Address: ______________________________________ _______ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Nameurable power of attorney for health care willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence. _______________________________________________ Address ____________________________________________________________ Statement by Witnesses (must be 18 or older) I declare that the person who signed this document appeared to execute the dhe event I become unable to make my own health care decisions. Signed this _________ day of ________________________ (month), 20____.(year) Signature___________________________________________________care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental health or personal care. This Durable Power of Attorney for Health Care shall take effect in t___________________ (telephone number of successor attorney-in-fact). My health care agent and any alternate health care agent shall have the authority to make all health care decisions regarding any ________________________________________________ (name of successor attorney-in-fact) _______________________________________________ (address of successor attorney-in-fact) __________________________ealth care decisions for me, except to the extent that I state otherwise. In the event the person I appoint is unable, unwilling or unavailable to act as my attorney-in-fact, I hereby appoint: ______________________________________________ (name) at __________________________________________________________ ( home address and telephone number of agent) as my health care agent to make any and all hDisclaimers and Terms of Use found at findlegalforms.com -2- Power of Attorney for Health Care I, ________________________________________________________, (name) hereby appoint: ___________________ent is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a documnd are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended ahorizing or encouraging euthanasia, assisted suicide, suicide, or any action or course of action that violates the criminal laws of this state or of the United States. [_] These forms are provided "astionships, and administration of estates, and nothing in this section shall be construed to affect in any way the provisions of § 28-1-101 et seq. (g) Nothing in this section shall be construed as autombined with a declaration made by a qualified patient under the foregoing act. (f) This section is wholly independent of the provisions of § 28-1-101 et seq. relating to wills, trusts, fiduciary relabe interpreted or construed to alter or amend any provision of the Arkansas Rights of the Terminally Ill and Permanently Unconscious Act, § 20-17-201 et seq. The powers of a health care agent may be cct or invalidate any health care agency executed or any act of an agent prior to July 1, 1999, or affect any claim, right, or remedy that accrued prior to July 1, 1999. Nothing contained herein shall least eighteen (18) years of age. (3) An agent appointed under a power of attorney for health care shall take precedence over any person listed in § 20-9-602. (e) This section does not in any way affeal or by someone acting at the direction of the principal and in the principal's presence; and -1- (C) Attested to by and subscribed in the presence of two (2) or more competent witnesses who are at ning treatments. (d) (1) A person may execute a power of attorney for health care. Such power of attorney may be durable. (2) The health care agency shall be: (A) In writing; (B) Signed by the principons concerning life-sustaining treatment set forth in § 20-17-201 et seq. However, a power of attorney for health care may contain the declaration set forth in § 20-17-202 relating to such life-sustains any care, treatment, service, or procedure to maintain, diagnose, treat, or provide for the patient's physical or mental health or personal care. (2) The term "health care" shall not include decisiower to make personal and health care decisions for the principal will be effective to the same extent as though made by the principal. (c) (1) For purposes of this section, the term "health care" meabecomes incapacitated, his or her right to control treatment may be denied unless the individual, as principal, can delegate the decision-making power to a trusted agent and be sure that the agent's p of Attorney for Health Care Act". (b) The General Assembly recognizes the right of the individual to control all aspects of his or her personal care and medical treatment. However, if the individual s Statutes relating to the Arkansas Power of Attorney for Health Care Form. 20-13-104. Durable power of attorney for health care. (a) This section shall be known and may be cited as the "Durable Powerrney for Health Care Form. This Arkansas Power of Attorney for Health Care is based on Title 20 Chapter 13 Section 20-13104 of the Arkansas Statutes. The following are useful excerpts from the ArkansaInformation and Instructions Arkansas Power of Attorney for Health Care This package contains (1) Information and Instruction for Arkansas Power of Attorney for Health Care; (2) Arkansas Power of Atto Arkansas