ARIZONA HEALTH CARE DIRECTIVE (LIVING WILL / HEALTH CARE POWER OF ATTORNEY) OF John Doe I, John Doe, being of sound mind and disposing mind and memory, do hereby make and declare this to be my health care directive, thereby revoking and making null and void any and all other health care directives, living wills, and health care powers of attorney previously made by me. [Section I appears if you choose to include a living will] I. LIVING WILL [This section will appear if you elect to be kept on life support.] I want my life to be prolonged to the greatest extent possible. [This section will appear if you elect to not be kept on life support and will vary depending on your choices.] If I have a terminal condition or an irreversible coma or a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do not want my life to be prolonged. I want the following: (a) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing. (b) Artificially administered food and fluids. (c) To be taken to a hospital. Page 1 DOC###########
I desire to receive treatment for comfort or to alleviate pain except as stated below: I do not want to receive mophine My initials below indicate my desires: [This section will only appear if you elect to not be kept on life support.] Notwithstanding my other directions, I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state. [This section will appear if you write additional health care instructions.] I further direct that: I want to be placed in hospice care if the doctors deem appropriate [Section II appears if you choose to appoint someone to make health care decisions for you. You can appoint an alternate agent if your first choice is unavailable.] II. HEALTH CARE POWER OF ATTORNEY I, John Doe, as principal, designate the following individual as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital, and related health care: Name: Jane Doe Relation: Spouse Address: 123 Main Street Glendale, Arizona 85301 Phone: (323) 962-8600 Alt. Phone: (323) 962-8600 Email: jadoe@legalzoom.com This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent s actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees, and personal representatives as if I were alive, competent, and acting for myself. Page 2
If Jane Doe is unwilling or unable to serve or continue to serve, I hereby appoint the following person as my agent: Name: Susan Doe Relation: Daughter Address: 123 Main Street Glendale, Arizona 85301 Phone: (323) 962-8600 Alt. Phone: (323) 962-8600 Email: sbdoe@legalzoom.com I completed the living will section above to provide specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. My agent is directed to implement my choices. [The following sections will vary if you place limitations of your agent s authority.] My agent may direct the disposition of my remains. My agent may give consent to an autopsy. Notwithstanding the foregoing, the authority of my agent is limited as follows: My agent is not authorized to transfer me to an assisted living facility. This health care directive is made under 36-3221, Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. [Section III varies depending upon your choices regarding organ donation.] III. ORGAN DONATION Pursuant to Arizona law, I hereby give, effective on my death: Any needed organ or parts. For: Any legally authorized purpose. Page 3
IV. GENERAL PROVISIONS If any provision hereof is held to be invalid, such invalidity shall not affect the other provisions of this document, and such other provisions shall be given effect without the invalid provision. Pursuant to the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) and any similar state laws, and exclusively for the purpose of making a determination of my incapacitation or inability to direct my own health care decisions and obtaining a physician affidavit of such, I authorize any health care provider to disclose to the person named herein as my health care agent or alternate health care agent, as applicable, any pertinent individually identifiable health information sufficient to determine whether I am by reason of illness or mental or physical disability incapacitated or incapable of directing my own health care decisions. In exercising such authority, my health care agent shall constitute my personal representative as defined by HIPAA. On the determination of my incapacitation or incapability to direct my own health care decisions, I intend for the person named herein as my health care agent or alternate health care agent, as applicable, to be treated as my personal representative under HIPAA and any similar state laws, and as such to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. It is my intent that this document be legally binding and effective. If the law does not recognize the legal validity of this document, it is my intention that this document be taken as a formal declaration of my intentions concerning all of the above provisions. Copies of this document have the same effect as the original. All persons or entities that in good faith endeavor to carry out the provisions of this document shall not be liable to me, my estate, or my heirs, for any damages or claims arising because of their actions or inactions based on this document. My estate shall indemnify and hold them harmless. Page 4
I, John Doe, the principal, sign my name to this power of attorney this day of and, being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly, or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes expressed in the power of attorney, and that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. Signature of John Doe Dated:, 20 123 Main Street Glendale, Arizona 85301 Page 5
WITNESS DECLARATIONS Under penalty of perjury, each of the undersigned declares that: (1) John Doe has been personally known to me (or that the individual s identity was proven to me by convincing evidence), and I believe him or her to be of sound mind and not under duress, fraud or undue influence; (2) John Doe signed or acknowledged this document in my presence, and I did not sign John Doe s signature; (3) I am not related to John Doe by blood, adoption, or marriage; (4) I am not entitled to any part of John Doe s estate or directly financially responsible for his or her medical care; (5) I am competent and at least eighteen years of age; (6) I am not John Doe s doctor or physician, or an employee of John Doe s doctor or physician; and (7) I am not the operator or an employee of a community care facility or a residential care facility for the elderly. Date: Signature: Print Name: Address: Date: Signature: Print Name: Address: Page 6
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