Arizona Healthcare Directives Registration Agreement

📌 What Is the Registration Agreement?

The Registration Agreement is the official form used to file your health care directives with the Arizona Healthcare Directives Registry (AzHDR) — a secure database managed by the Arizona Secretary of State. Filing this agreement ensures that your medical wishes are accessible to licensed health care professionals when you can’t speak for yourself.

Once registered, you’ll receive a wallet-sized membership card with access instructions for emergency providers.

✅ Here is the Free Fillable PDF for the Agreement

Registration Agreement

✅ What You Can Do with the Agreement

You can use the Registration Agreement to:

• File a new health care directive (such as a Medical Power of Attorney or Living Will)

• Replace an existing directive already stored in the registry

• Add another document to an existing file (like a DNR or mental health directive)

• Remove your directive entirely from the registry

• Update your registration information (such as your mailing address)

• Request a replacement wallet card

🧾 What You’ll Need to Complete It

Before you start, gather the following:

• Your completed Medical Power of Attorney form (and any other health care directives you wish to file)

• Your full name, address, phone number, and date of birth

• The last 4 digits of your Social Security Number

• The name as you’d like it printed on your membership card

• (Optional) A different mailing address if you want your documents and card shipped somewhere else

🧠 Important Concepts to Know

• Medical Power of Attorney (MPOA): A legal form that designates someone to make medical decisions on your behalf if you become incapacitated.

• Advance Directive: A general term for legal documents that express your health care preferences, including MPOAs, Living Wills, and DNR orders.

• Membership Card: A card issued by the state once you register — keep it in your wallet so emergency providers can access your directives fast.

📦 How to Submit the Registration Agreement

1. Complete the online or paper form with your personal and contact information.

2. Select the action you want (e.g., file a new directive, request a new card).

3. Upload or attach your completed health care directive(s).

4. Sign the agreement and include a notarized form if required.

5. Submit it to the Arizona Secretary of State (by mail or online, depending on format).

Once approved, you’ll receive:

• A confirmation of registration

• Your official wallet card

• A record in the Arizona Healthcare Directives Registry

💡 Tips to Make It Easy

• Use your legal name as it appears on your directive.

• Only Arizona residents can file with the AzHDR.

• Make copies of your directive and registration for your doctor, health care agent, and family.

• If you need to update later, you can submit a new Registration Agreement at any time.

📬 Where to Send Your Forms

Arizona Secretary of State – Advance Directive Registry Mail your forms: Arizona Healthcare Directives Registry – Contexture 2901 N. Central Ave., Ste. 1100 Phoenix, AZ 85012

Email your forms: azhdr@contexture.org

👀 What Happens After You Submit?

• Your directive is reviewed and securely added to the state registry.

• Your membership card is mailed to the address you provided.

• Health care providers can access your information if needed — using your name, DOB, and SSN last four digits.

👥 Need Help?

If you have questions or want someone to walk you through the process, Helpful can guide you. Please contact us today here