Arizona Medical Power of Attorney Template
This Medical Power of Attorney allows you to designate someone to make healthcare decisions on your behalf in Arizona, as permitted under Arizona Revised Statutes § 36-3201 et seq.
Principal Information:
- Name: ______________________________
- Date of Birth: ______________________
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- City: ______________________________
- State: Arizona
- Zip Code: __________________________
Agent Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: ______________________________
- State: _____________________________
- Zip Code: __________________________
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own healthcare decisions, as determined by my attending physician.
Agent's Authority:
I grant my agent the authority to make any and all healthcare decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Making decisions about life-sustaining treatment.
Limitations:
My agent's authority is subject to the following limitations:
- ____________________________________________________________________
- ____________________________________________________________________
Signature:
By signing below, I affirm that I am of sound mind and that I understand the purpose of this document.
Signature of Principal: ___________________________
Date: _________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
Witness 1 Name: ______________________________
Witness 1 Signature: __________________________
Date: ______________________________________
Witness 2 Name: ______________________________
Witness 2 Signature: __________________________
Date: ______________________________________
Notarization:
State of Arizona, County of ______________________
Subscribed and sworn before me on this _____ day of ______________, 20__.
Notary Public Signature: ______________________
My Commission Expires: ______________________