The Medical Power of Attorney in Arizona refers to a form that permits a relative or companion to deal with the clinical necessities of someone else. The power of attorney is composed by an individual known as the principal for when they can't address clinical personnel by themself. This is normal because of some critical sicknesses such as Alzheimer's Disease, Dementia, or sickness emanating because of undergoing a medical procedure recently. The Medical Power of Attorney can be dropped by the principal by finishing the POA revocation.
Signing Requirements (§ 36-3221(a)(3)) – One witness and a Public Legal (Notary) Official.
Statute – § 36-3224
1. Open The Form Once The Reference Information Has Been Gathered
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2. The Principal of this Authority will need to be identified in the first section by entering the requested information
Some blank spaces that are tagged have been supplied to execute this effectively. The Principal’s name should be entered on the space tagged “My Name”. Then the Address of the Principal should be entered on the blank that is tagged “My Address”.
There are blank spaces on a column found on the right side of this form that requests the date of birth, phone number, and age. The blank spaces tagged “My Date of Birth”, “My Telephone Number” and “My Age” should be utilized to supply these details.
3. Declare The Identity Of The Agent And Provide Contact Information
The subsequent segment will likewise have a few spaces that request details, notwithstanding, this will be for the Representative or Advocate. In other words, the individual that will possess the Authority to make decisions medically in regard to the wellbeing of the Principal. The first thing to do is to utilize the spaces tagged “Address” and “Name” to supply the Representative’s complete name as well as to enter the Residential location of the Representative.
On the right side of this form is a column of clear spaces. This second segment should have the Contact Data of the Representative. The Residential Phone Number, Workplace Phone number, and Cell Telephone number of the Representative should be entered on the clear spaces tagged “Home Phone”, “Work Phone”, and “Cell Phone”.
This part will likewise take into account a backup Agent to be chosen and documented by the Principal. This chosen individual will execute the obligations of the Representative if they are unable, incapable, or are no longer permitted to use the powers to make decisions medically for the Principal. Beneath the assertion beginning with "I choose the following person to act…," the clear spaces that are tagged "Name," "Address," "Home Phone," "Work Phone," and "Cell Phone" should be utilized to record the backup agent’s identification details, residential location, and contact data.
4. Read The Third Item, Then Document The Principal's Limitations
A few of the activities and choices a Representative might influence because of this form will be clearly defined in section 3. It should be ensured that the Principal comprehends these assertions and every engaging rule. As soon as this assignment is finished, the Principal should report any limits, conditions, specifications, or limitations on the blank line underneath the assertion beginning with "I do not want my representative… " found in the fourth Section.
5. The Principal's Autopsy Preferences
The fifth item supplies a part where the Principal might unveil their inclinations regarding getting an autopsy after their demise. The title “My specific desires about autopsy” should be located. Underneath the “Note” box there will be three blank spaces and statements that will be supplied. Assuming the Principal doesn't agree to get Autopsy after their demise, they should indicate or imprint the clear space that comes before the phrase “Upon my death, I DO NOT consent…” In case the Principal desires an Autopsy after passing, then they should imprint or indicate in the blank space that comes before the subsequent declaration.
The Principal might choose to ascribe the Representative or Agent the authority to execute this directive. If this is so, then it is required for them to imprint or indicate it in the 3rd declaration.
6. The Principal Anatomical Gift Preferences
The sixth segment, "My specific desires about organ donation..," provides two basic declarations. Assuming that the Principal doesn't desire to give out any Organ for donation (that is Anatomical Gifts), they should indicate and imprint Option A. Assuming that the Principal wishes to make an Organ donation, they are required to indicate by imprinting Option "B," then, at that point, continue to the inquiries underneath to additionally supply a clear definition of how you want the Organ donation to be carried out.
Assuming the Principal has demonstrated that they desire to give out organs for donation, then the first item permits a few guidelines to be added. If it is desired by the Principal to give out their entire body, they should indicate in bubble “A”, any required Organs/Parts by indicating on the bubble “B”, or explicit organs/parts by indicating on the bubble “C”. It should be noted that if “C” is selected, the specified organs/parts should have a clear definition on the blank spaces that are numbered underneath this decision.
The item that comes next will permit the Principal to rapidly list the reason why the organs are to be donated (assuming any). Assuming that the Principal approves Organs Donation to be given for any lawful reason, the bubble that comes first should be ticked and filled up completely. In case the Principal will just endorse Organ Donations for Therapy or Transplanting, then it should be indicated in bubble "B". Assuming the Principal will just permit Organ Donations for Study, then it should be indicated on bubble “D”. The Principal might have other explicit reasons why they want their organs donated. If this is the case, bubble “D” should be selected, then the reason that was chosen by the principal should be supplied on the space provided.
The Principal might likewise have inclinations concerning the location where organs can be donated. In the third item, the Principal might list the Institution or entities that their Anatomical Gifts might be given. Bubble “A” should be filled in case the Principal has effectively consented to a composed contract with an entity or organization beneficiary and record the details of identification of this individual on the spaces given.
Assuming there is no arrangement like this but the Principal desires their organs to be donated to an individual specified, then bubble “B” should be ticked and the name of the individual should be entered on the space given. If the principal desires, he can elect the Representative or Agent to execute this choice on his or her behalf by indicating in Bubble “C”.
7. The Option To Define Disposition
In case the Principal has inclinations or directions in regards to "Burial Disposition and Funeral” plans, this should be supplied in the seventh section. This segment will have a rundown of items and a blank space that comes after them. It is required for the principal to indicate or check these declarations.
In case the Principal desires that their body be buried, then, they should indicate in the declaration that comes first.
Assuming the Principal desires that their body is buried and wants explicit directions to be executed in regards to their burial, then, at that point, they should indicate in the declaration that comes second. A space will be provided in the second declaration where it is expected for the principal to list what the explicit guidelines are.
The Principal additionally has the choice of coordinating a funeral by incineration. If this is the case, then they should indicate it in the third declaration.
If a funeral by incineration is desired by the Principal and has put guidelines in place for this purpose, then they should indicate in the fourth declaration.
It might be desired by the Principal to let a Representative settle on this kind of choice. If this is the case, then they should indicate it in the fifth declaration. This will give the representative the authority to execute burial, cremation, or funeral choices for the Principal.
8. A Principal's Living Will Should Be Reported In This Document
On the off chance that a Living will have been endorsed by the Principal; this is meant to be appended to this document and specified properly. The eighth section with the heading “About A Living Will” should be located. If the Living Will has been properly endorsed and appended, then they should indicate in Choice “A”, then the finished and entire Living will be appended. If this isn’t so, it should be indicated by the principal that they have not endorsed a Living Will and hence, this kind of form is not appended by indicating in Choice3 “B”.
9. The Principal's Resuscitation Instructions
Assuming a Preclinical Health Care Mandate or DNR Directive has been endorsed by the Principal on a paper that has an orange background, then this should be attached and indicated in Option “A”. If this is not the case, then, it should be indicated in Option “B”.
10. The HIPAA Waiver
If the Principal approves the Representative to have similar freedoms in regards to exposure and utilization of the Medical or Health data of the Principal as indicated by the HIPAA (Health Insurance Portability and Accountability Act) of 1996, then, at that point, it should be indicated on the blank space that is adjacent the declaration in the tenth section. If this is not the case, then this declaration should not be marked.
11. The Principal's Clear Approval And Verification
The section titled "Signature or Verification” should be located. It is required for the principal to put a signature on the space tagged “My signature” in Item "A". As soon as this is completed, the date of the signature should be correctly entered by the Principal on the blank space tagged “date”.
A clause has been provided in item B on the off chance that the Principal is not able to put a signature on this form. In this area, an observer that has been given guidelines on how to verify the directions of this form may put a signature on this form to approve its validity. If so, this observer should carefully peruse the declaration in item B, then imprint their name on the blank tagged “Witness Name” as well as put a signature on the line tagged “Signature”. The Signature Date needs to be supplied by the individual signing this document on the blank space that comes after the term “Date”.
12. Second Party Verification
This signature on this form can be confirmed by one observer who is an adult or a Public Legal (Notary) Official. If the signature on this form will be confirmed by an observer, it is required for this observer to supply their name and sign accordingly. The Signature Date should be supplied on the line that is tagged “Date” and the residential location of the observer should be supplied utilizing the blank space that comes after the term “Address”.
If the signature on this form will be approved by a Legal (Notary) Official, the Legal (Notary) Official will be required to complete the section that starts with the terms “Notary Public”. This individual is the only authorized person that is required to supply any data on this section and put a seal with a valid notary stamp.
13. Physician Statement
If the Principal has completely talked about the Guidelines that they have entered on this document with a Doctor, it is advised for the Doctor to put a signature on the Statement of the Physician as this will help to confirm the comprehension of the Principal’s authority in this form (in addition to other items).
There are a few blank spaces below the title “Statement That You Have Discussed Your Health Care Choice for the Future with your Physician”. It is required for the Doctor that concurs with this declaration to imprint their names on the line that is tagged “Doctor Name”. Beneath this, the doctor is required to put a signature as well as the date of signature in the spaces given. In the end, the residential location should be supplied by the Doctor on the line that is tagged “Address”.
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