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DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS FOR
JOHN DOE
Pursuant to Arizona Revised Statute 36‑3221, I hereby create this Durable Power of Attorney for Health Care Decisions to authorize the agent designated to make all health care decisions for me at any time that I am not able to communicate my wishes or not able to make health care decisions for myself. Pursuant to Arizona Revised Statutes 14‑5501 et seq and 36‑3223, this Durable Power of Attorney for Health Care Decisions will not be affected or revoked by my incapacity or other disability. Pursuant to Arizona Revised Statute 36‑3202, this Power of Attorney for Health Care Decisions continues in effect for all who may rely on it except for those who have received notice of its revocation.
PURPOSE. My purpose is to grant my agent designated below the full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. This power and authority is effective on, and only on, my inability to make or communicate my own health care treatment decisions. For purposes of this document, Ahealth care treatment decision@ means consent, refusal of consent or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition.
APPOINTMENT OF AGENT. I appoint the following persons, in the order of priority set forth, to act as my agent for purposes of this Durable Power of Attorney for Health Care Decisions:
1. N-2- (state relationship) 2. N-3- (state relationship) 3. N-4- (state relationship)
It is my desire that, to the extent reasonable and practical, my agent who is acting pursuant to this Durable Power of Attorney for Health Care Decisions consult with all of the above named persons before exercising the authority granted in this document. Neither the attending physician nor the hospital is required to determine if any or all of the above named persons have been consulted or contacted or the reason why certain individuals may not have been consulted or contacted. Any physician or other health care provider may rely on the avowal of authority of any secondarily‑named agent acting on my behalf if that agent provides a written statement to the person with whom he is dealing as to why any of the previously‑named agents cannot make health care treatment decisions for me.
POWERS OF AGENT. My agent has the power and authority to do any and all of the following: 1. To consent, refuse or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, psychiatric treatment, artificial respiration, nutritional support and hydration and cardiopulmonary resuscitation. 2. To request, review , receive and otherwise obtain access to any information, written or oral, regarding my physical or mental health, including all medical and hospital records. 3. To authorize my admission to or discharge from (even against medical advice) from any hospital, nursing home, residential care, assisted living or similar facility or service. 4. To contract on my behalf for any health care related service or facility. 5. To hire or fire medical, social service or other support personnel for my care 6. To make advance arrangements for my funeral and burial or cremation, including the purchase of a burial plot and marker and any other such related arrangements as my agent deems appropriate. 7. To make anatomical gifts of my bodily parts in a manner not inconsistent with any written organ donation declaration that I may have previously or contemporaneously completed. 8. I have completed a Living Will which provides specific direction to my agent in situations that may occur when I am terminally ill and unable to make or communicate health care treatment decisions. My agent is directed to implement the choices I have made in the Living Will. and its terms are expressly incorporated into this Durable Power of Attorney for health care decisions.
9. HIPAA Release Authority. 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 and shall constitute both consent and authorization for the use and disclosure of my records as those terms are defined under the HIPAA Privacy Rule. I authorize:
(1) any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider and any insurance company and Medical Information Bureau Inc. Medical Information Bureau Inc that has provided treatment or services to me or that has paid for or is seeking payment from me for such services (2) to give, disclose and release to my agent, without restriction,
(3) all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse.
The authority given my agent shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information.
This HIPAA release authority shall also apply to any of my children or other family members named in this document, even if they are not my agent. It is very important to me that my entire family be apprised of my condition even if those family members are not acting as my agent. In other words, all of my family members set forth above shall have full disclosure to my individually identifiable health information even if they are not in acting in a decision-making capacity.
I have carefully read and reviewed this document in its entirety and hereby express my agreement with its contents by signing below.
DATED THIS d-t.
By: JOHN DOE, Principal
The witnesses who sign below a) are not named as an agent for the person who signed this Durable Power of Attorney for Health Care Decisions, b) are not directly involved with the provision of health care to the person who signed this Durable Power of Attorney for Health Care Decisions at the time it was signed, and c) are not related to the person signing this Durable Power of Attorney for Health Care Decisions by blood, marriage, or adoption or otherwise entitled to receive any part of the estate of the person who signed this Durable Power of Attorney for Health Care Decisions.
STATE OF ARIZONA ) ) ss. COUNTY OF MARICOPA )
Subscribed, sworn to, and acknowledged before me by JOHN DOE and subscribed and sworn to before me by and , Witnesses, this d-t.
(Name of Notary), Notary Public
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
PRINCIPAL: JOHN DOE N1-ad N1-tl
AGENT: N-2 N2-ad N2-tl
FIRST ALTERNATE AGENT: N-3 N3-ad N3-tl
SECOND ALTERNATE AGENT: N-4 N4-ad N4-tl
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