Arizona Health Care Power of Attorney (POA)

📄 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

1. Sign the form correctly with a witness or notary

2. Make copies for:

   • Your agent(s)

   • Your doctor(s)

   • Your hospital or care facility

   • Your records at home

3. Attach other advance directives if you have them

4. 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.