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Arkansas Durable Power of Attorney for Health Care Form

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Arkansas Durable Power of Attorney for Health Care Form grants a trusted friend or relative the power (pursuant to § 20-13-104) to make medical decisions on his or her behalf should the principal not have the capacity to do so. This is a useful document to have in place before you have surgery or some other scheduled medical procedure where you will be under anesthesia. In addition, it is something that will be helpful in the event of an unscheduled trip to the hospital.

Laws – § 20-13-104

Living Will – Use to choose options in the event the patient would like to deny life-sustaining treatments if they should be in an incurable state.

Durable (Financial) Power of Attorney – When the principal becomes incapacitated, this document will allow their trusted representative to take control of their finances.

How to Write

1 – Obtain The Required Form

This form may be used as a PDF, ODT, or Word file. Simply select file type using the buttons beneath the image on the right to begin.

2 – Identify the Declarant

On the blank line labeled “Name of Declarant,” report the Name of the Principal granting power to a Health Care Agent through this document.

3 – Designate The Health Care Agent

In the main paragraph, enter the Name of the Health Care Agent on the blank space following the term “I hereby designate and appoint.”

4 – Declare the Successor Health Care Agent

In the second paragraph, enter the full Name of the Health Care Agent (named in the first paragraph) on the blank line following the word “If.”

On the second blank space, enter the full Name of the individual who will assume the Health Care Agent authority and responsibility should the primary Health Care Agent be unable to carry out this role.

5 – Declare the Signature Date

On the line beginning with the words “Signed this…,” report the Calendar Day of the Month this form is being signed. Then on the next two blank spaces, report the Month and the Year this form is being signed.

6 – Declarant’s Signature

On the blank space below the date, the Declarant (or Principal) must Sign his or her name.

7 – Provide Witness Testimony

Two Witnesses will need to Sign this document after physically watching the Declarant Sign this form.

In the paragraph beginning with the words “We, the undersigned…” enter the full Name of the Declarant on the blank space. Below this paragraph, each Witness will have a column of lines to provide his or her Signature and Address


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