Arizona Health Care Power of Attorney (POA)
This document allows you to legally name a trusted person (your “agent”) to make health care decisions for you if you become too ill or injured to make those decisions yourself. It also lets you make choices about autopsy, organ donation, and funeral or burial wishes — all in one form.
Get insurance benefits, legal documents, and medical records in one place

📄 Download the Full Arizona Life Care Planning Packet (PDF)
🧭 What Is a Health Care Power of Attorney?
This form:
Names someone to act on your behalf for health care decisions
Grants them access to your medical records (if you choose)
Gives you the option to specify instructions they must follow
Remains in effect until you revoke it, or unless changed by court order
This document is only activated if you're unable to make your own medical decisions.
📝 Step-by-Step Instructions
Section 1: Your Information
What it asks:
Your full name
Date of birth
Address
Phone number and email
Helpful Tip: Use your legal name as it appears on your ID or medical records.
Section 2: Appoint Your Health Care Agent
What it asks:
Name and contact info of your primary agent
Optionally list a backup agent
Helpful Tip: Choose someone who knows your values and will be calm under pressure. Talk to them in advance and make sure they agree to serve.
Section 3: Authority of Your Agent
You may authorize your agent to:
Make any and all medical decisions if you can’t
Access your medical records (HIPAA waiver included later)
Respect limits you choose to list
You can also specify what decisions they cannot make, if any.
Section 4: Autopsy Instructions
You choose one (initial only one):
Do not consent to a voluntary autopsy
Do consent
Let your agent decide
Helpful Tip: Autopsies are usually not required unless legally mandated (e.g., criminal investigation), but they can help families understand cause of death.
Section 5: Organ Donation Options
You may:
Opt out entirely
Indicate you've already arranged for donation
Select specific organs/tissues, donation purposes, and recipients
Let your agent decide
Helpful Tip: Include any known arrangements (e.g., donor card, university program) and be clear about your preferences.
Section 6: Funeral & Burial Preferences
Choices include:
Burial (and preferred location)
Cremation (and where ashes go)
Letting your agent decide
Helpful Tip: While not legally binding in the same way as a will, this section can guide your family and reduce confusion or disagreement.
Section 7: Reference to Other Documents
You can indicate if you have:
A Living Will
A POLST (for end-of-life emergency treatment)
A DNR (Do Not Resuscitate directive)
Helpful Tip: If yes, attach copies to this form and store them together. Consider registering them with AZHDR.
Section 8: HIPAA Waiver
You can initial to give your agent full legal access to your protected health records, just like you would have.
Highly recommended for effective decision-making.
Section 9: Signature and Witnessing
You must sign this form in front of either:
One qualified adult witness, OR
A notary public
Do not do both.
Witnesses/notaries cannot be:
Under 18
Related to you
Named as your agent
Anyone entitled to your estate
Your health care provider
✔️ Final Steps
Sign the form correctly with a witness or notary
Make copies for:
Your agent(s)
Your doctor(s)
Your hospital or care facility
Your records at home
Attach other advance directives if you have them
Register online (optional) at azhda.org
🛠️ Need Help?
Helpful can guide you through this form, answer questions about your options, and assist with registration and sharing. You don’t have to do this alone.
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