Establishing secure connection…Loading editor…Preparing document…

Durable Healthcare Power of Attorney Arizona Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

STATE OF ARIZONA
DURABLE HEALTH CARE POWER OF ATTORNEY
Instructions and Form

GENERAL INSTRUCTIONS:

Use this Durable Health Care Power of Attorney form if you want to select a person to make future health care decisions for you so that if you become too ill or cannot make those decisions for yourself the person you choose and trust can make medical decisions for you. Talk to your family, friends, and others you trust about your choices. Also, it is a good idea to talk with professionals such as your doctor, clergyperson and a lawyer before you sign this form.

Be sure you understand the importance of this document. If you decide this is the form you want to use, complete the form. Do not sign this form until your witness or a Notary Public is present to witness the signing. There are further instructions for you about signing this form on page three.

1. Information about me: (I am called the “Principal”)

My Name:

My Address:

My Telephone:

My Age:

My Date of Birth:

2. Selection of my health care representative and alternate: (Also called an "agent" or "surrogate")

I choose the following person to act as my representative to make health care decisions for me:

Name:

Street Address:

City, State, Zip:

Home Telephone:

Work Telephone:

Cell Telephone:

I choose the following person to act as an alternate representative to make health care decisions for me if my first representative is unavailable, unwilling, or unable to make decisions for me:

Name:

Street Address:

City, State, Zip:

Home Telephone:

Work Telephone:

Cell Telephone:

3. What I AUTHORIZE if I am unable to make medical care decisions for myself:

I authorize my health care representative to make health care decisions for me when I cannot make or communicate my own health care decisions due to mental or physical illness, injury, disability, or incapacity. I want my representative to make all such decisions for me except those decisions that I have expressly stated in Part 4 below that I do not authorize him/her to make. If I am able to communicate in any manner, my representative should discuss my health care options with me. My representative should explain to me any choices he or she made if I am able to understand. This appointment is effective unless and until it is revoked by me or by an order of a court.

The types of health care decisions I authorize to be made on my behalf include but are not limited to the following:

▸ To consent or to refuse medical care, including diagnostic, surgical, or therapeutic procedures;

▸ To authorize the physicians, nurses, therapists, and other health care providers of his/her choice to provide care for me, and to obligate my resources or my estate to pay reasonable compensation for these services;

▸ To approve or deny my admittance to health care institutions, nursing homes, assisted living facilities, or other facilities or programs. By signing this form I understand that I allow my representative to make decisions about my mental health care except that generally speaking he or she cannot have me admitted to a structured treatment setting with 24-hour-a-day supervision and an intensive treatment program – called a “level one” behavioral health facility – using just this form;

▸ To have access to and control over my medical records and to have the authority to discuss those records with health care providers.

4. DECISIONS I EXPRESSLY DO NOT AUTHORIZE my Representative to make for me:

I do not want my representative to make the following health care decisions for me (describe or write in “not applicable”):

5. My specific desires about autopsy:

Upon my death I DO NOT consent to (want) an autopsy.

Upon my death I DO consent to (want) an autopsy.

My representative may give or refuse consent for an autopsy.

6. My specific desires about organ donation: (“anatomical gift”)

A. I DO NOT WANT to make an organ or tissue donation, and I do not want this donation authorized on my behalf by my representative or my family.

B. I DO WANT to make an organ or tissue donation when I die. Here are my directions:

1. What organs/tissues I choose to donate: (Select a or b below)

a. Any needed organ or parts.

b. These parts or organs:

1.)

2.)

3.)

2. What purposes I donate organs/tissues for: (Select a, b, or c below)

a. Any legally authorized purpose (transplantation, therapy, medical and dental evaluation and research, and/or advancement of medical and dental science).

b. Transplant or therapeutic purposes only.

c. Other:

3. What organization or person I want my parts or organs to go to:

a. I have already signed a written agreement or donor card regarding organ and tissue donation with the following individual or institution: (Name)

b. I would like my tissues or organs to go to the following individual or institution: (Name)

c. I authorize my representative to make this decision.

7. About a Living Will:

A. I have SIGNED AND ATTACHED a completed Living Will in addition to this Durable Health Care Power of Attorney to state decisions I have made about end of life health care if I am unable to communicate or make my own decisions at that time.

B. I have NOT SIGNED a Living Will.

8. About a Prehospital Medical Care Directive or Do Not Resuscitate Directive:

A. I and my doctor or health care provider HAVE SIGNED a Prehospital Medical Care Directive or Do Not Resuscitate Directive on paper with ORANGE background in the event that 911 or Emergency Medical Technicians or hospital emergency personnel are called and my heart or breathing has stopped.

B. I have NOT SIGNED a Prehospital Medical Care Directive or Do Not Resuscitate Directive.

SIGNATURE OR VERIFICATION

I intend for my agent 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. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.

A. I am signing this Durable Health Care Power of Attorney as follows:

My Signature:

Date:

B. I am physically unable to sign this document, so a witness is verifying my desires as follows:

Witness Verification:

I believe that this Durable Health Care Power of Attorney accurately expresses the wishes communicated to me by the principal of this document. He/she intends to adopt this Durable Health Care Power of Attorney at this time. He/she is physically unable to sign or mark this document at this time, and I verify that he/she directly indicated to me that the Durable Health Care Power of Attorney expresses his/her wishes and that he/she intends to adopt the Durable Health Care Power of Attorney at this time.

Witness Name (printed):

Signature:

Date:

SIGNATURE OF WITNESS OR NOTARY PUBLIC:

A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who signed this Durable Health Care Power of Attorney appeared to be of sound mind and under no pressure to make specific choices or sign the document. I understand the requirements of being a witness and I confirm the following:

I am not currently designated to make medical decisions for this person.

I am not directly involved in administering health care to this person.

I am not entitled to any portion of this person's estate upon his or her death under a will or by operation of law.

I am not related to this person by blood, marriage, or adoption.

Witness Name (printed):

Signature:

Address:

Date:

Notary Public

NOTE: If a witness signs your form, you DO NOT need a notary to sign.

STATE OF ARIZONA ) ss

COUNTY OF )

The undersigned, being a Notary Public certified in Arizona, declares that the person making this Durable Health Care Power of Attorney has dated and signed or marked it in my presence and appears to me to be of sound mind and free from duress. I further declare I am not related to the person signing above by blood, marriage or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in providing health care to the person signing. I am not entitled to any part of his/her estate under a will now existing or by operation of law. In the event the person acknowledging this Durable Health Care Power of Attorney is physically unable to sign or mark this document, I verify that he/she directly indicated to me that this Durable Health Care Power of Attorney expresses his/her wishes and that he/she intends to adopt the Durable Health Care Power of Attorney at this time.

WITNESS MY HAND AND SEAL this day of , .

Notary Public My Commission Expires:

OPTIONAL:

STATEMENT THAT YOU HAVE DISCUSSED
YOUR HEALTH CARE CHOICES FOR THE FUTURE
WITH YOUR PHYSICIAN

On this date I reviewed this document with the Principal and discussed any questions regarding the probable medical consequences of the treatment choices provided above. I agree to comply with the provisions of this directive, and I will comply with the health care decisions made by the representative unless a decision violates my conscience. In such case I will promptly disclose my unwillingness to comply and will transfer or try to transfer patient care to another provider who is willing to act in accordance with the representative's direction.

Doctor Name (printed):

Signature: Date:

Address:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Durable Healthcare Power of Attorney Arizona Form Is

The Durable Healthcare Power of Attorney Arizona Form is a legal document that lets an individual designate another person to make medical and healthcare decisions on their behalf if they become unable to decide. It specifically addresses health-care treatment choices and can survive the principal’s incapacity when executed according to Arizona requirements. The form typically names a primary agent and alternate agents, may include scope limitations, and can incorporate preferences about life-sustaining treatment, organ donation, and access to medical records.

Why this form matters for patients and families

Completing a Durable Healthcare Power of Attorney Arizona Form clarifies who can make medical decisions, reduces family conflict, and ensures your care preferences are followed if you cannot speak for yourself.

Why this form matters for patients and families

Who typically completes this Arizona healthcare POA

Individuals planning for incapacity commonly complete this form to designate decision-makers and state treatment preferences.

  • Adults with chronic or progressive health conditions who want a trusted agent to act for them.
  • Elderly individuals arranging end-of-life preferences and appointing healthcare proxies.
  • Caregivers and family members seeking clarity on authority and treatment boundaries.

The form is also used by healthy adults as a prudent advance-planning document; it becomes effective under the conditions you specify.

Primary signers and their roles

Principal

The person creating the Durable Healthcare Power of Attorney who appoints an agent. The principal must be an adult with capacity at signing and should state the effective date and any limitations on authority in clear terms to avoid later disputes.

Agent

The individual or alternate named to make healthcare decisions when the principal lacks capacity. The agent should understand the principal’s values, be willing to make difficult medical choices, and have access to medical information and treating providers.

Essential fields and data elements

Principal name: Full legal name
Agent name: Full legal name
Alternate agent: Optional name
Effective date: MM/DD/YYYY
Scope of authority: Specific powers
Signatures: Principal and witness/notary

Consequences of errors or missing elements

Invalid execution: Document may be unenforceable
Mismatched names: Banks or providers may refuse
Missing witness: State may require notarization
Vague scope: Agent authority may be contested
No agent available: Court-appointed guardian may be required
Outdated form: Preferences may not reflect current wishes

Common preparation pitfalls to avoid

  • Using informal language that leaves treatment choices ambiguous; precise phrasing prevents later disputes over life-sustaining measures or scope limits.
  • Failing to confirm witness or notary rules in Arizona before signing; signature formalities vary and affect enforceability.
  • Not sharing copies with healthcare providers and the named agent; an unsigned or inaccessible form cannot guide urgent care decisions.
  • Choosing an agent without discussing values and practical availability; disagreements or inability to act can delay critical care.

Step-by-step: completing the Arizona durable healthcare POA

Follow these practical steps to prepare, execute, and distribute the Durable Healthcare Power of Attorney Arizona Form correctly.

  • 01
    Choose agent: Select someone trustworthy and available
  • 02
    Complete form: Fill all required fields clearly
  • 03
    Sign and notarize: Follow Arizona witness/notary rules
  • 04
    Distribute copies: Give copies to agent and providers

How the executed form is used by providers

After execution, the form guides providers and the agent; here are the practical steps organizations follow when presented with the document.

  • Verification: Provider confirms identity and signatures
  • Acceptance: Form is placed in medical record
  • Agent access: Agent obtains medical information
  • Decision-making: Agent exercises authority per form

Digital workflow settings for online completion

Configure these settings when using an eSignature platform to ensure valid execution and secure distribution.

Field Configuration
Signature block Require signer signature and date
Witness fields Enable witness name and signature entries
Authentication Use email + SMS or knowledge-based checks
Audit trail Capture IP, timestamp, and actions

Technical considerations for eSigning a healthcare POA

Ensure the eSignature platform supports required authentication, audit logs, and secure storage for healthcare documents.

  • Authentication: Multi-factor recommended
  • Audit trail: Immutable timestamps required
  • HIPAA readiness: BAA must be available

Verify the vendor supports HIPAA workflows and provides retrievable audit trails so the executed form is accepted by healthcare providers.

eSignature vendor comparison for executing healthcare POAs

Compare common pricing and capability points when selecting an eSignature provider for healthcare POA workflows. signNow is listed first per vendor alignment rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Yes, trial available Yes, trial available Yes, trial available Yes, trial available
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions about the Arizona healthcare POA

Answers to common questions about validity, witnesses, notarization, revocation, and electronic signing for the Durable Healthcare Power of Attorney Arizona Form.


Need help? Contact support

Explore Templates

Castle Rock v. Gonzales JDF 481 Affidavit of Presumptive Paternity Motion for Publication of Notice Self Help Adoption Forms Colorado Self Help Adoption Forms Transcript Request Form
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.