Arizona Advance Directive Form

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An Arizona advance directive lets an individual select a health care agent to make decisions on their behalf and make end-of-life treatment selections. The agent selected should be a spouse, family member, or close friend. The agent will have the right to make any medical decision that is aligned with the person’s wishes. For end-of-life treatment options, a person may choose to keep themselves alive as long as possible or negate food, water, and breathing assistance if they should be permanently incapacitated.

Advance Directive Includes

Table of Contents

Laws

StatutesTitle 36, Chapter 32 (Living Wills and Health Care Directives)

Signing Requirements (§ 36-3224§ 36-3262) – One (1) witness or a notary public.

Registering

To register an advance directive, complete the Registration Form and send to the following address:

Secretary of State
Attn: Advance Directive Dept.
1700 W. Washington Street, Fl 7
Phoenix, AZ 85007

Versions (2)


Arizona Attorney General

Download: Adobe PDF

 

 

 


Northern Arizona Healthcare

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Step 1 – Obtain The Arizona Life Caring Planning Packet From This Site

The Arizona Health Care Planning Packet will deliver several forms that combine as the Advance Directives in Arizona. Use the “PDF” button presented with the form’s preview or the “Adobe PDF” link in this section to download it.

Step 2 – Familiarize Yourself With The Information Introducing The Directive Forms

Review the first few pages of the “Life Care Planning Packet” as this will present a wealth of material concerning subject matter ranging from registering your directive with the Arizona Advance Directive Registry to your rights as a Patient.

 

Step 3 – Resister Your Advance Directive With The Arizona Secretary Of State

Once you have completed reading the introduction, locate the “…Wallet-Sized Notice IN Case Of Accident Or Other Emergency” card placed near its conclusion. Fill in your “Name,” the current “Date,” and check off the directives being issued. The bottom of this card will require a contact name who has more information (i.e. your Health Care Representative or a Trusted Family Member” along with the “Telephone Number” needed to initiate contact. This card should be cut out as a whole then kept in your wallet. 

 

Step 4 – Document Your Full Name As The Issuing Principal For The Registration

Once you have reviewed the full introduction, locate the “Arizona Health Care Directives Registry” form on page fourteen. This form is optional but is strongly recommended as it allows you to register your entire combined directives with the Arizona Secretary of State. To begin the registration process, populate the first row of empty boxes in this form with your “Last Name,” “First Name,” and “Middle Name.” Be advised this must be the name of the person issuing the directives. Thus, if preparing this document for another entity, produce the Principal or patient’s full name to this area. 

 

Step 5 – Attach Your Address Of Registration For The Arizona Directives

In addition to the Principal’s name, the full address where the Arizona Principal lives. Two rows of boxes labeled “Address” then “City,” “State,” and “Zip” to satisfy this requirement. Utilize the first of these objects to record the building number, street name or number, and apartment number of the Principal. Continue the required address on the next line by supplying the appropriate “City,” “State,” and “Zip” code accordingly.

 

Step 6 – Produce Additional Items To Verify Your identity

The “Phone” number where the Principal can be reached along with his or her birthday and the “Last Four Digits OF Social Security Number” assigned to the Principal must be supplied where these items are requested. 

 

Step 7 – Furnish Your Desired Membership Name

The Arizona Health Care Directives Registry will send the issuing Principal a membership card. Produce your name as you wish it to appear on this membership to the next empty box. 

 

Step 8 – Provide The Arizona Secretary Of State With Return Address Information

If the Principal issuing these Arizona Directives has a mailing address that is different from the residential address previously defined, then complete the box holding the “Name” label with the name of the official Recipient that must be addressed to have materials sent to the Principal.

In addition to the Name of the Recipient, the first line of his or her mailing information should be produced on to the boxes labeled “Address,” 

Make sure to conclude the Principal’s formal mailing address with its “City,” “State,” and “Zip” distributed across the next three boxes.

 

Step 9 – Establish Your Intention For This Registration

The registration form being should be submitted with a basic intention reported. A checklist at the end of it will allow a quick report of this intention or reason. Mark the first checkbox after the words “I Want To” if you are submitting this form to “Store A Health Care Directive(s) In The Registry”  If you already have a directive(s) stored and wish to replace it then mark the checkbox labeled “Replace A Health Care Directive(s) Now In The Registry With A New One”This document may be submitted simply because a directive was not included in the original registration. If this is the case, then mark the third checkbox (found next to the statement starting with “Add An Additional Document…”)If this registration is submitted with the intent of removing current health care directives, then select the checkbox corresponding to the word “Remove.”Mark the fourth checkbox if the purpose this registration is being made is to “Request A Replacement Wallet Card” with absolutely no changes made to your current registration or directives. If this registration results because the current name on file for the Principal, address on file (home or mailing), or social security number must be updated then mark the checkbox attached to the “Change Registration Agreement Information (Such As A New Address)

 

Step 10 – Execute The Your Registration Form

Locate the box labeled “Signature Of Person Completing This Agreement” and the box labeled “Date.” These items can be found at the end of the registration form’s disclosure and acknowledgment statement. Sign your name to testify to the accuracy of the form’s information, then produce the date (currently) in the adjacent box.  Below your signature, supply your “Printed Name” as this will facilitate proper storage and retrieval of your registration when needed.  

 

Step 11 – Issue A Durable Power Of Attorney Effective In Arizona If Desired

If you desire to include an Arizona Durable Health Care Power of Attorney, then locate page sixteen in the Arizona Advance Directive Packet (otherwise known as the Arizona Health Care Planning Packet”). Review the “General Instructions” box to introduce yourself to this paperwork. 

 

Step 12 – Identify Yourself As The Arizona Principal

The first task this appointment requires is a record of your name as the Arizona Principal. Article “1. Information About Me (The Principal)” provides a line labeled “My Name” and one labeled “My Age.” Furnish these items with your first, middle, and last name then your current age where each detail is requested. Your home address and your birthday should also be dispensed as a means of solidifying your identity. The “My Address” line and “My Date Of Birth” line will accommodate these entries. Finally, complete your self-report by delivering your contact phone number on the “My Telephone” number line.  

 

Step 13 – Formally Designate The Arizona Health Care Representative And An Alternate

The Health Care Representative you name to in this document will act with the same authority you possess to make medical decisions over your treatment options when an Arizona Physician requires guidance while you are unconscious or otherwise unable to represent yourself. Be advised that it will be assumed the Health Care Representative you designate will be fully abreast of the belief systems you hold that would have a powerful effect on your treatment preferences. The “Name” of your Arizona Health Care Representative must be presented on the first available line in “2. Selection Of My Health Care Representative And Alternate (“Agent” Or “Surrogate”) section to formally designate the person of your choosing to this role. Once you have named this individual as your Health Care Representative (Agent or Surrogate) you must provide some contact information beginning with his or her residential telephone number on the “Home Phone” line.  Continue documenting the means to contact your Arizona Health Care Representative with his or her home “Address,” “Work Phone” number, and “Cell Phone” number where requested. Make sure these items are up-to-date and well-monitored by the Health Care Representative you are appointing with principal authority.  The individual you appointed as your Health Care Representative or Agent may be not always be able to act in this role. This may be due to unforeseeable events such as having to suddenly travel, his or her authority revoked, or any other reason. Should this happen, you can still make sure that someone of your choosing has the authority to safeguard your medical preferences by naming an Alternate Health Care Representative. That is, an individual who will not be granted the principal power needed to represent you until your official Health Care Representative steps down has this right revoked, or it becomes obvious he or she will not be available in time to answer the attending Arizona Physician’s questions. Use the blank line labeled “Name” beneath the statement starting with the words “I Choose The Following Person To Act As An Alternate Representative…” to designate a second choice to the Health Care Representative role then the “Home Phone” line to document his or her telephone number.  After identifying your choice for Alternate Health Care Representative utilize the lines labeled “Address,” “Work Phone,” and “Cell Phone” to dispense the information needed to reliably contact this Party should it become necessary.  

 

Step 14 – Place Limits On Your Arizona Health Care Representative’s Powers If appropriate

The third article in this appointment (titled “3. I Authorize If I Am Unable To Make Medical Care Decision For Myself”) is set with the language needed to grant your Health Care Agent the representational authority needed to act on your behalf when you cannot. Review this material as it will dictate what may be expected of your Health Care Agent.

The next section that requires attention is Article “4. Decisions I Expressly Do Not Authorize My Representative To Make For Me.” If any of the actions listed in the third article should be restricted from the Health Care Agent’s granted powers if you wish to place certain conditions on his or her ability to represent you in certain situations, or if you wish to place any limitations on the health care decisions your Agent will be allowed to make on your behalf, then use the space provided to document these provisions otherwise if you are comfortable with your Health Care Representative acting to the full capacity this role allows when making medical treatment decisions on your behalf, then produce the words “Not Applicable” to this space.

 

Step 15 – Discuss Autopsy Consent

Once death occurs, the subject of an autopsy must be addressed. At times, the state will require an autopsy performed regardless of anyone’s wishes (i.e. when a crime occurs) however, you may set a directive indicating whether you consent to a voluntary autopsy. If you “…Do Not Consent To A Voluntary Autopsy” then initial the blank line attached to the first statement item in “5. My Specific Desires About Autopsy.”  If you wish to “…Consent To A Voluntary Autopsy” performed upon death, then initial the second statement item in “5. My Specific Desires About Autopsy.”  You may wish to opt-out of making this decision on paper or have informed your Health Care Representative of specific instances when you believe an autopsy is acceptable and when it is not. In either case, you may formally designate the power to make this decision to your Health Care Representative by initialing the third statement item in “5. My Specific Desires About Autopsy.” 

 

Step 16 – Issue A Statement On Organ Donation

In addition to the topic of an autopsy, article “6. My Specific Desires About Organ Donation (“Anatomical Gift”)” seeks a definition to your stance on organ donation. If you do not wish to grant consent for an anatomical gift or organ donation to be made upon death, then initial item A of this section.  If you do grant your consent to make an organ donation, then initial item B. This requires further definition. If you do intend to donate organs or anatomical gifts then continue to the first item in this choice.  If you have consented to an organ donation, then you must indicate the extent of the anatomical gifts you wish to make in item “1. What Organs/Tissues I Choose To Donate.” An anatomical gift consisting of your entire body then fill in the bubble bearing the statement “A. Whole Body.” If you wish anatomical gifts made only if needed (as opposed to storage) then fill in the bubble corresponding to “Any Needed Parts Or Organs” You may designate only certain tissues, organs, or body parts by filling in the bubble labeled “C. These Parts Or Organs Only” then producing a list of the approved anatomical gifts to the available blank lines.  You may also define why your organs should be donated in “2. What Purpose I Donate “Organs/Tissue For.” Review the list provided in this item. If you have determined that your anatomical gifts may be delivered for any reason, then mark the first bubble in this item.  Set “Transplant Or Therapeutic Purposes Only” as the single reason you would approve an organ donation by selecting the second statement’s bubble. If you wish anatomical gifts made for “Research Only” then fill in the bubble labeled “C. Research…”You may have specific reasons in mind for making an organ donation or anatomical gifts. If you wish to deliver a detailed account of where or why you wish anatomical gifts made, then choose the final bubble of this list “D. Other” and document this reason directly to the blank line provided.

Item 3 of this article allows you to document where anatomical donations may be made. If you have already made arrangements to donate your organs to a specific organization then select the first bubble presented. Furnish the blank space in this option with the full Organ Donation Recipient’s legal name and address.

If you have not made any anatomical gift arrangements but wish your organs, tissues, and other body parts to be donated to a preferred organization or human being then select option “B. I would like to…” After selecting this option, utilize the blank line in this choice to define where you prefer your anatomical donations to be made.

You may also use this item to grant your Health Care Representative to decide upon the identity of your Anatomical Gifts Recipient by selecting the “C” bubble.

 

Step 17 – Indicate Your Burial Or Funeral Preferences

The next section is optional and may be left blank however, if desired you can use article “7. Funeral And Burial Disposition (Optional)” to also include directions regarding your body once it is released with the death certificate. The first two options will allow you to communicate that you want your body buried. If you do not have instructions beyond this then select the first statement by initialing the blank line before it. If you wish to deliver specific burial instructions, then initial the second statement and place your directions on the empty line provided.  You may wish your body to be cremated. If so, then initial the “Upon My Death, I Direct My Body To Be Cremated” statement.  The fourth statement declares your desire to be cremated and includes a line where you can deliver specific instructions for your ashes.  If you wish the Health Care Agent, you named with the authority to handle this matter for you then initial the statement beginning with “My Agent Will Make All Funeral And Burial…”

 

Step 18 – Declare The Status Of Your Living Will

The eighth article labeled with the term “8. About A Living Will” allows you to inform Reviewers of this document as to whether you have executed and attached a living will. If so, then initial item “A. I Have Signed And Attached…”     If you have not signed a living will (attached or otherwise) then initial the blank line attached to “B. I Have Not Signed A Living Will.”   

 

Step 19 – Furnish A Statement Defining If A DNR Is Issued

Article “9. About A Prehospital Medical Care Directive Or Do Not Resuscitate Directive” requires that you report the status of the DNR otherwise known as a Do Not Resuscitate Order. If your doctor and you have completed (and signed a Do Not Resuscitate Directive (or Prehospital Medical Care Directive”) then initial the statement “A. I And My Doctor Or Health Care Provider Have Signed…” If you have not issued a DNR, then initial the blank line corresponding to the second statement (“B. I Have Not Signed A Prehospital Medical Care Directive Or Do Not Resuscitate Directive”).  

 

Step 20 – Confirm Or Refuse To Dispense A HIPAA Waiver Of Confidentiality For Your Agent

While your Health Care Agent has been set to receive your medical information, a separate statement will need to be initialed if you want her to have the same to information as the Health Insurance Portability And Accountability Act of 1996, then you must initial the statement in “10. HIPAA Waiver Of Confidentiality For My Agent/Representative.” 

 

Step 21 – Execute The Arizona Durable Power As Yourself Or Using A Proxy

The “Signature Or Verification” section will begin the process of finalizing your appointment. Item A of this section provides your statement of intention. If you agree with the information on the completed appointment and the wording produced by item A., then sign the “My Signature” line. This action also requires that you report the “Date” that you signed this document on the adjacent line.  If this document is being signed by Proxy (a trusted family member or formally designated Appointee) then this Proxy must print his or her name on the “Proxy Name (Printed)” line, after reading through the “Proxy Verification” statement. Once the Proxy’s name is presented, the Proxy must sign the “Signature” line then produce the “Date” the Proxy signed this paperwork. 

 

Step 22 – Validate Your Signature With A Presentation Of Witness And Notary Testimonials

The signing you produced must be done before a Witness and a Notary Public. Therefore, after completing and signing this appointment release it to the possession of the Witness in attendance. The Witness must read through the “Signature Of Witness” section then print his or her name on the “Witness Name (Printed)” line.  Once done, make sure the Witness signs his or her name to the “Signature” line and documents the signature “Date” on the next available line.  Finally, the “Address” lines must be completed with the home address of the Witness. A Notary Public viewing these signings will notarize this document in the “Notarial Jurat “section with a formal record of the document being notarized, its signature date, and the signing’s location. This area must also include the Notary’s credentials and seal.   

 

Step 23 – Obtain Your Physician’s Acknowledgment By Signature

If you have discussed this document with your Physician, then you may use this document to obtain a signed statement to this effect. Present this document to your Physician so that he or she may read the Physician’s declaration then produce his or her printed name, signature, signature date, and address where requested. This is an optional task but recommended by many nonetheless.   

 

Step 24 – Issue Your Durable Mental Health Care Power Of Attorney

The Arizona Advance Directive allows for the execution of a Durable Mental Health Care Power Of Attorney. As with the previous designations, the Arizona Mental Health Care Representative will be able to represent your preferences with treatments when you are no longer able to maintain cognizance, communication, or consciousness. The “General Instructions” section of this paperwork will present important information such as who may declare you as unable to deliver informed consent for treatments (i.e. A Neurologist licensed in the state of Arizona). 

 

Step 25 – Identify Yourself As The Arizona Principal

The first article that must be tended with information in this appointment can be found with the title “1. Information About Me.” As the Principal who intends to appoint a Mental Health Care Representative you must document your full name on the line labeled “My Name” then furnish your age in years to the next available line on the right (labeled “My Age”). Once you have self-reported, locate the set of lines labeled “My Address” where you must furnish a report of your full home address as it appears on your government issued ID (for instance, your Driver’s License or Arizona State ID). Once completed, direct your attention to the right where the lines labeled “My Date Of Birth” and “My Telephone” should be used to display your birthday then home phone number or cell phone number. 

 

Step 27 – Designate Your Mental Health Care Representative And An Alternative

Now that you have identified yourself as the Principal, it will be time to designate your Mental Health Care Representative. Article “2. Selection Of My Health Care Representative And Alternative…” seeks the full “Name” of your Mental Health Care Representative reported on the first empty line and his or her home telephone number documented on the second blank line (“labeled “Home Phone”).  Naturally, it is imperative that Mental Health Professionals be able to contact your appointed Mental Health Care Agent whenever necessary. Facilitate this ability by documenting the “Address,” “Work Phone” number, and “Cell Phone” number where Mental Health Care Providers can reliably and quickly contact your Agent. The next area of the second article enables an Alternative Health Care Agent to be set up. This Party can be thought of as a Mental Health Care Agent who is held in reserve in case your primary choice steps down, has his or her power of representation revoked, is unavailable, or cannot represent you. When this happens the authority, you granted to your Mental Health Care Agent will automatically be transferred to the Alternative Health Care Representative. Locate the first blank line (labeled “Name”) below the words “…If My First Representative Is Unavailable, Unwilling, Or Unable To Make Decisions For Me” then furnish the first, middle, and last name of your desired Alternative Health Care Agent to this line before proceeding to report his or her “Home Phone” number. The “Address” where your Alternative Mental Health Care Representative can be found as well as his or her “Work Phone” number and ” Cell Phone” number should be distributed to the blank lines bearing these labels.  

 

Step 28 – Discuss The Powers Granted To The Mental Health Care Representative

The mental health decision-making powers that are being granted to the Mental Health Agent must be documented within this appointment form. The third article (“3. Mental Health Treatments That I Authorize If I Am Unable To Make Decisions For Myself” presents for items (A through D). You must check the box corresponding to the description of mental health care decisions you authorize your Mental Health Care Agent to make on your behalf. You may check one, some, or all of the statements presented. Begin with “A. About My Records.” If you wish the Mental Health Care Agent to be able to “…Receive, Review, And Consent” to sharing your mental health records on your behalf then mark the checkbox attached to this item.  If the Mental Health Representative should have the authority to consent or deny medications for your treatment, then check the box labeled “B. About Medications”  Check or mark the box labeled “C. About A Structured Treatment Setting” to authorize your Mental Health Care Agent to admit you to an inpatient psychiatric facility (a facility providing 24-hour supervision and treatment).  You may delegate specific decision-making powers to your Mental Health Care Representative by marking “D. Other” then specifically naming these abilities.  

 

Step 29 – Limit The Administration Of Mental Health Treatments If Desired

In addition to approving the powers above and/or delegating additional representational authority to your Mental Health Care Representative, an area where you may place restrictions or conditions on any of these powers. The space provided in “4. Durable Mental Health Treatments That I Expressly Do Not Authorize” will accept a report on the treatments you intend to explicitly refuse. This takes the decision out of your Mental Health Care Representative’s scope of powers. If you wish to document any such refusals, then use the space labeled “(Explain Or Write In “None”)” to present these wishes but if you trust that your Mental Health Care Agent is fully aware and in complete agreement with your treatment preferences or do not need to strictly forbid specific treatments then, write in the word “None” on the blank line.  

 

Step 30 – Produce More Mental Health Directives As Needed

Article “6. Additional Information” will allow you to put your mental health care treatment preferences, directives, and concerns to paper. This is a free form area that allows you to deliver instructions on subjects ranging from dietary requirements to religious considerations. You may leave this line unattended or produce the word “None” if no such additional information need to be provided.   

 

Step 31 – Include A HIPAA Waiver Of Confidentiality To Increase Your Agent’s Power

To give your Mental Health Care Representative named through this designation the same right to information as you possess as mandated by the Health Insurance Portability And Accountability Act of 1996″ then initial the blank line in the “HIPAA Waiver OF Confidentiality For My Agent/Representative.”  

 

Step 32 – Execute This Appointment Personally Or Through A Proxy

Once this document is complete, review it to make sure all the information it contains is current and accurate. The “Signature Or Verification” section contains a line labeled “My Signature” and a line labeled “Date.” You must sign your name to this line as the Principal issuing this document then establish the day you signed it by recording the current “Date” on the next line.   If you are a Proxy formally issuing this document because the Principal is unable to and can agree to the “Proxy Verification” statement made in item B of the “Signature Or Verification” section, then you must print your name on the “Proxy Name (Printed)” line.  The Proxy executing this form must do so on the “Signature” line and present the “Date” of signature directly underneath his or her printed name.    

 

Step 33 – Obtain Arizona Witness Verification And Notarization For The Signing

At least one Witness must have observed the execution of this paperwork. If this Witness has read the declaration made in the “Signature Of Witness” section and can verify its accuracy, then the Witness must print his or her name on the first blank line provided. The “Signature” line requires the Witness sign his or her name while the “Date” line next to it requires the signature “Date” entered. Finally, the Witness must report his or her “Address” to the final area of the “Signature of Witness” section’s item “A. Witness.” The “Notarial Jurat” can only be completed by a Notary Public who has viewed the signing. You may have a Witness or a Notary verify this form but not both. If a Notary Public is being used for verification, then he or she will subject this section to the notarization process which will name the location, date, and signature party for the signing before documenting the notary seal and required credentials.  

 

Step 35 – If Needed, Acquire Proof Of The Mental Health Care Representative’s Acceptance

The final page of the mental health designation appointment being completed is “Optional: Representative’s Acceptance Of Appointment.” It is suggested (though not required) that the Mental Health Care Representative be presented with the executed designation, read through it, then print and sign his or her name on the “Representative Name (Printed)” line and “Signature” line to agree with the statement made under the words “Representative’s Acceptance Of Appointment.” He or she must also produce the signature “Date” on the final line in this area.

 

Step 36 – Document Your End Of Life Care Preferences

The living will portion of the Arizona Advanced Directive can be found on the twenty-fifth page. To set you directives when an end-of-life event occurs, and death is unavoidable find the Arizona Living then read the “General Instructions section. 

 

Step 37 – Produce Your identity And Contact Information As The Principal

The first article in this paperwork is titled “1. My Information (The “Principal”)” and seeks your full “Name” and “Age” produced on the top two blank lines. Document your residential “Address” as well as your “Date Of Birth” and “Phone” number on the final three lines of this section. 

 

Step 37 – Establish Your End Of Life Preferences

The second article is set with several items that require review. In the second article, “2. My Decisions About end Of Life Care,” several statements defining issues that will come up during a medical event that will result in death will be documented. You may initial one or all of them however, as the introduction to this section mentions, the final statement should not be marked if any of the previous ones are. This will create confusion since statement E contradicts the previous ones. Read the introduction to this section for more information. If you have determined that you do not wish to be subjected to life-prolonging treatment when death is imminent but wish to be kept comfortable, clean, and pain free then initial item “A. Comfort Care Only.” You may wish to place “Specific Limitations On Medical Treatments I Want” when you are in a permanent coma or have a terminable or irreversible condition by initialing item B then tending to the list it provides.  If you have installed item B, then you must review the list this item presents. Statements 1 through 3 list different life saving maneuvers that will be administered by default in most cases unless you initial the item you do not wish. For instance, if your heart or lungs stop functioning then Cardiopulmonary Resuscitation methods such as drugs, electric shock, or physical handling may be administered to force the organ to maintain your life with the hopes that you will recover. If you initial number one of this list, you will indicate that you do not condone or authorize the use of CPR (cardiopulmonary resuscitation) to be administered.  Initial number two of this list if you do not wish “Artificially Administered Food And Floods” delivered to your system when you are unable to feed yourself.  A significant number of people prefer not to go to a hospital during an end of life event. If you do not wish to be taken to a hospital unless necessary (i.e. being in extreme pain) then initial number three of this list then initial the third option.  If as the Principal, you wish to receive life-sustaining treatment only when it is known you are pregnant and a reasonably good chance of the embryo’s survival exists, then initial “C. Pregnancy.” Be advised this statement will supersede all other statements while pregnant if it is initialed.   If you are unable to communicate or in a persistent vegetative state and there is either a question as to how permanent this or there is a possibility that your condition is not irreversible or terminal, you may wish to receive medical treatment. If you wish your life sustained right up until the point a formal diagnosis of being terminal, permanently unconscious, with no hope of recovery or a cure then initial item D. Keep in mind this means that when you are diagnosed as incurable and it is known that death is imminent your end of life directives will automatically be placed.   If you wish your life prolonged “…TO the Greatest Extent Possible” then initial “E. Direction To Prolong My Life.” If you have initialed any of the items above, then you may not choose this directive.   

 

Step 38 – Indicate If Other Directives Containing End Of Life Care Are Attached

The third article, labeled “Other Statements Or Wishes I Want Followed For End Of Life Care” must be reviewed before proceeding to the signing. If there are no additional preferences to be considered a part of this document, then select the box labeled “A. I Have Not Attached…”  If you have additional provisions regarding your end of life care and they are attached, then mark the statement labeled “B. I Have Attached Additional Special Provisions…”   

 

Step 39 – Execute Your Arizona Living Will Before A Witness Or Notary Public

If you are issuing this living will as the Principal, then locate the item labeled “A. I Am Signing This Living Will As Follows” in the “Signature Verification” section. Execute this document by signing the “Signature” line then displaying the current “Date” on the next line.   If you are a Proxy issuing this living will on behalf of the Principal, then read through the “Proxy Verification” statement under “B. I Am Physically Unable To Sign This Living Will So A Proxy Is Verifying…” Once done the Proxy is instructed to print his or her name on the “Proxy Name” line.  The Proxy must sign the “Signature” line and dispense the signature “Date” where requested to complete his or her obligation in executing this paperwork.  If the executing signature of this living will is to be authenticated by a Witness’s testimony, then the Witness must review the “Signature Of Witness” section once the Principal (or Proxy) has signed it. If in agreement with the contents of this section, the Witness should print his or her name on the first available line.  The “Signature” and “Date” line must be completed by the Witness. He or she must sign the former item then record the “Date” on the latter item.  Finally, the Witness must supply his or her “Address” on the final line of this section.  If a Notary Public will be used as verification to this document’s signing, then he or she must complete the Notarial Jurat section with the facts regarding the Principal (or Proxy) signature. This requires a report on date, location, parties, and the Notary’s seal and signature. 

 

Step 40 – Inform Your Arizona Health Care Representatives Of Their Appointment

The Health Care Representatives you have named in this document as your primary Agent and you Alternative Health Care Representative may be formally informed of their appointment using the “Letter To My Representative(s)” page. You may find this letter on page 28. Take a moment to review it before continuing.

When you are ready to complete this letter then issue it, locate the two columns at the top of the page. Utilize the “Name” line in the first column to address your primary Health Care Representative by supplying his or her full Name to this line then, continuing to the “Alternative Health Care Representative” column on the right, address your Alternative Health Care Agent by “Name” on the first line of this column. Next, record the full address of the Health Care Representative and Alternate Health Care Agent directly below each one’s name on the “Address” lines provided.  Article “A. What I Ask You To Do For Me” provides two items that require definition. If you are using this letter to inform the Health Care Representatives above that each is appointed to their respective roles in an attached “Durable Health Care Power Of Attorney, “then you must initial the blank line next to the number “1” in this article.  If you are informing the Agents that each is named as such in your “Durable Mental Health Care Power Of Attorney,” then initial line “2.” You may initial one of these items or both.  Conclude this correspondence by signing the “Signature” line then dating this signature on the “Date” line.  Conclude the letter by printing your name on the “Print Name” line.  

 

Step 41 – If Desired Issue A Prehospital Medical Care Directive

As mentioned in most of the previous documents, a DNR can be issued by the Principal. This will formally refuse the administration of CPR to resuscitate you should your heart or lungs cease operation. The final page of this document is the “Prehospital Medical Care Directive (Do Not Resuscitate).” You may issue this at will with the cooperation of your Physician, but it must be produced (printed) on orange paper. Read the introduction to this document to become familiar with its issuing requirements.  The first item of the DNR seeks your signature on the “Patient Signature” line, your printed name displayed on the “Patient’s Printed Name” line, and the “Date” you have provided these items.   Two choices are presented to provide a positive physical identification to attending Arizona Physicians. You may either supply your physical description by reporting your birth date, sex, race, eye color, and hair color (see below) or you may attach a recent photograph.  The second article requires the attending Physician’s full name, “Telephone” number, and the “Hospice Program” that will attend to you (if this is applicable).  Article “3. Signature Of Doctor Or Other Health Care Provider” seeks your Physician’s signature and signature date provided on the lines “Signature Of A Licensed Health Care Provider” and “Date” (respectively).   This document requires that either a Witness provide a “Signature” and signature “Date” in “Signature Of Witness To My Directive”

 

 

Related Forms


Durable Financial Power of Attorney

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Last Will and Testament

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