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REVOCABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS FOR * 1. Designation of Primary Health Care Agents. Pursuant to Arizona Revised Statutes Sections 14-5104, 36-2271, and 44-133, we, N-1 and N-2 , are the lawful parents of *, a child born on _(birthdate)_______________, under the age of eighteen years old. We are of sound mind, free from any duress or undue influence, and over the age of eighteen years. We hereby willfully and voluntarily designate and appoint the following to act as our Agents to make health care decisions for us concerning our minor child, *. Primary Agents: N-3 . (For the purpose of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedures to maintain, diagnose, or treat our child’s physical or mental condition.) 2. General Statement of Authority Granted. We grant our Agents full power and authority to make health care treatment decisions concerning our child for us to the same extent that we could make such decisions concerning our child. In exercising this authority, our Agents shall make health care decisions that are consistent with our desires as stated in this document, or as otherwise made known to our Agents, including, but not limited to, our desires concerning obtaining, refusing, or withdrawing life-prolonging care, treatment services, and procedures. 3. Insurance Coverage Insurance Carrier: Name of Insured: Policy Number: Primary Care Physician Phone number: 4. Statement of Limitation. If our child should suffer from an incurable or terminal condition or disease, or is in an irreversible coma, we direct that our Agents make all possible attempts to locate us and inform us of our child’s condition prior to authorizing any health care provider to stop further treatment. If our Agents cannot locate and inform us of such an event after all known means of contacting us have failed, our Agents are then, and only then, authorized to order medical personnel to refuse or withdraw life-prolonging care, treatment, services, and procedures. We do not wish for our child to receive medical treatment that will only postpone the moment of death from an incurable or terminal condition or disease or that will prolong an irreversible coma. (For the purpose of this instrument, "terminal condition" shall refer to a condition or disease that is reasonably expected to result in death within twelve (12) months regardless of the treatment received and "irreversible coma" shall refer to a permanent loss of consciousness from which there is no reasonable possibility to return to a cognitive and sapient life and shall include, but shall not be limited to a "persistent" or permanent vegetative state.) 5. Inspection and Disclosure of Information Relating to Physical or Mental Health. Subject to any limitations in this document, our Agents have the power and authority to do all of the following: a. Request, review, and receive any information , verbal or written, regarding the physical and mental health of our child, including, but not limited to, medical and hospital records. b. Execute, on our behalf, any releases or other documents that may be required in order to obtain this information. c. Consent to the disclosure of this information. 6. Signing Document, Waivers, and Releases. Where necessary to implement the health care decisions that our Agents are authorized by this document to make, our Agents have the power and authority to execute on our behalf all of the following: a. Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice." b. Any necessary waiver or release from liability required by a hospital or physician. 7. Time Period of Agents’ Authorization. Pursuant to Arizona Revised Statute Section 14-5104, our Agents’ authorization in this document will last for six months, beginning on the day on which this document is signed by us, unless it is terminated prior to that time by both of us. Revocation by one parent is effective as to that parent only. Revocation may be done orally or in writing. It continues in effect for all who may rely on it except those to whom we have jointly given notice of its revocation. 8. Declaration of Anatomical Gift (Organ Donation). (You may make a gift of all or part of your child’s body to bank or storage facility or a hospital, physician, or medical or dental school for transplantation, therapy, medical or dental evaluation or research, or for the advancement of medical or dental science. You may also authorize your Agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself or state that you do not want to make a gift. If you do not complete this section, your Agent will have the authority to make a gift of a part of your child’s body pursuant to law.)
We thereby make the following anatomical gift of the understated organs or parts of our child’s body to take effect immediately upon death. The initials in the appropriate blanks and words filled in on the blank lines below indicate our earnest desires and intentions in this regard.
to the following person(s) [or institution(s)]:
for the following purpose(s):
It is our intention that this Medical Directive, both as a self-executing document and as a delegation of power to our Agents and health care provider, shall be deemed an exercise of all rights that we may have under the United States Constitution, the constitution of the state of our domicile, state and federal laws, rules, regulations, and decisions, judicial and administrative, to refuse medical treatment, artificial nutrition and artificial hydration. Dated this d-t
On the date set out hereinabove, N-1 and N-2 , personally known to us, executed and dated this Revocable Power of Attorney for Health Care Decisions for * in our presence, and N-1 and N-2 appeared to be of sound mind and free from duress.
STATE OF ARIZONA ) ) ss. County of Maricopa ) Acknowledged before me this d-t by N-1 and N-2 , the Principals, and by Paralegal Name, a Witness.
Attorney Name Attorney at Law, Notary Public
STATE OF ARIZONA ) ) ss. County of Maricopa )
Acknowledged before me this d-t by N-1and N-2 , the Principals, and by Attorney Name, a Witness. Paralegal Name, Notary Public
REVOCABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS FOR MINOR
PRINCIPALS: N-1 and N-2 Address AGENTS: N-3 Address
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DURABLE POWER OF ATTORNEY FOR N-1 By this instrument, I intend to create a Durable Power of Attorney as set forth in Arizona Revised Statute 14-5501 et seq. This Power of Attorney shall not be affected by any subsequent disability or incapacity of myself, the principal. I, N-1, hereby appoint my_____, N-2, to serve as my agent ("Agent") and to exercise the powers and discretions set forth below. I hereby revoke all Powers of Attorney, general or limited, granted by me as Principal, prior to the date I have signed this instrument, except that any powers granted by me on forms provided by financial institutions granting the right to write checks on, deposit funds to, and withdraw funds from accounts to which I am signatory or granting access to a safe deposit box shall not be revoked and shall continue in full force and effect. ARTICLE I ADVISORY NOTICE TO AGENT. THERE HAVE BEEN RECENT CHANGES TO ARIZONA REVISED STATUTE SECTION 14-5506, A STATUTE WHICH GOVERNS THE EXERCISE OF POWERS OF ATTORNEY. UNDER THAT NEW STATUTE, AN AGENT CANNOT RECEIVE ANY BENEFITS FROM THE PRINCIPAL UNLESS THOSE BENEFITS ARE SPECIFICALLY IDENTIFIED IN DETAIL WITHIN THIS INSTRUMENT OR WITHIN A WRITTEN CONTRACT. OTHERWISE, THE AGENT COULD BE SUBJECT TO CRIMINAL PROSECUTION OR SUBJECT TO THE PENALTY PROVISIONS OF ARIZONA REVISED STATUTE SECTION 46-456, WHICH AUTHORIZES THE LOSS OF THE AGENT’S RIGHT TO INHERIT FROM THE PRINCIPAL AS WELL AS PAYMENT OF TREBLE DAMAGES AND ATTORNEY’S FEES. AN AGENT SHOULD CAREFULLY REVIEW THESE STATUTES OR CONSULT WITH A KNOWLEDGEABLE ATTORNEY PRIOR TO EXERCISING THE AUTHORITY GRANTED BY THIS POWER OF ATTORNEY. ARTICLE II My Agent is authorized, in my Agent’s sole and absolute discretion, from time to time and at any time, with respect to any and all of my property, real, personal, intangible, and mixed as follows: Power to Sell or Convey. My Agent is authorized to sell or convey any and every kind of property that I may own now or in the future, real, personal, intangible, or mixed, including without being limited to contingent and expectant interests, all marital rights, my share of any community property rights, and any rights of survivorship incident to joint tenancy or tenancy by the entirety. Any such sale or conveyance shall be upon such terms and conditions as my Agent deems appropriate. My Agent is authorized to make such dispositions of the proceeds of such sale as my Agent shall deem appropriate. This authority shall include the power to sell, transfer or encumber my residence, as well as any other real estate that I now have or later will acquire. Property located at: Legal description : (Use this paragraph only if the client has a home.)
Power to Buy. My agent is authorized to buy every kind of property, real, personal, intangible, or mixed, upon such terms and conditions as my Agent shall deem appropriate. This includes the authorization to obtain options with respect to such purchases and to arrange for appropriate disposition, use, safekeeping, or insuring of any such property. Power to Borrow and Use Credit Cards. My Agent is authorized to borrow money and to secure such borrowings in such a manner as my Agent shall deem appropriate. My Agent is authorized to use any credit card held in my name to make such purchases and to sign such charge slips as may be necessary to use such credit cards. Power to Provide for Principal’s Support. My Agent is authorized to do all acts necessary for maintaining my customary standard of living, to provide living quarters by purchase, lease, or other arrangement, or by the payment of the operating costs of my existing quarters, including interest, amortization payments, repairs, and taxes, to provide normal domestic help for the operation of my household, and to provide clothing, transportation, medicine, food, and incidentals for me. Power to Repay Loans. My Agent is authorized to repay, from any funds belonging to me, any money borrowed by me or my Agent acting on my behalf, and to pay for any purchases made by me or my Agent acting on my behalf. Power to Invest. My Agent is authorized to invest all or any part of my property in any property, real, personal, intangible, or mixed, wherever located, in whatever manner my Agent deems appropriate. This includes the power to establish, utilize, and terminate accounts, including margin accounts, with any stock transfer agent or securities broker and to exercise all rights with respect to any securities that I may now own or subsequently acquire. To invest in an IRC section 529 plan, Coverdell (fka Education)IRA, Roth IRA or similar tax-preferred investment. Power with Respect to Bank Accounts. My Agent is authorized to establish or terminate accounts of all kinds, including checking, savings and certificates of deposit, for me with financial institutions, including, but not limited to, bank and thrift institutions. My Agent is authorized to modify, terminate, make deposits to, write checks on, make withdrawals from, or grant security interests in all accounts in my name or with respect to which I am an authorized signatory (except accounts held by me in a fiduciary capacity). This authorization includes contracting for any services rendered by any financial institution. Power to Operate Businesses. My Agent is authorized to continue the operation of any business (including any rental properties, ranch or farm) belonging to me or in which I may have a substantial interest, for such time and in such a manner as my Agent shall deem appropriate. This power includes, but is not limited to, hiring and discharging employees; paying employees’ salaries; providing for employees’ benefits; employing legal, accounting, financial, and other consultants; continuing, modifying, terminating, renegotiating, and extending any contractual arrangements made by me or on my authorized behalf: executing business tax returns and other government forms required to be filed by my business; contributing additional capital to the business; changing the form of the business, incorporating or reorganizing the business, entering into partnership agreements and joining in any consolidation and merger of the business; selling, liquidating or closing out the business; to create, continue, and terminate retirement plans of the business, and to make contributions which may be required to those plans; and to borrow and pledge business assets. Power to Disclaim, Renounce, Release, or Abandon Property Interest. My Agent is authorized to renounce, disclaim, release, or abandon any property or interest in property to which I am or may become entitled, whether by gift, testate, or intestate succession. Power with Respect to Taxes. My Agent is authorized to represent me in all tax matters. This includes preparing, signing, filing and paying federal, state, and local income, gift, sales or excise tax returns, and extensions and waivers of applicable periods of limitation, filing protests and petitions to administrative agencies and courts, negotiating checks payable for tax refunds, and filing any tax related documents, including any power of attorney form required by the Internal Revenue Service and any other state or local taxing authority with respect to any tax year. I intend for this instrument to be the equivalent of Internal Revenue Service Form 2848 or other similar form used by state and local taxing authorities. Power to Provide Support for Others. My Agent is authorized to support any person whom I have undertaken to support or to whom I owe an obligation of support, in the same manner as I may have provided in the past, adjusted if necessary by circumstances and inflation. If at any time I am legally separated or divorced from my spouse, any support provided to such spouse by my Agent shall be limited to such support as may be required by law. Power For Spouse to Exercise Community Property Rights. Need Paralegal’s & Client’s initials on all these blank spaces)______________________In the event I have appointed my spouse as my Agent and to the extent not otherwise expressly prohibited by the terms of this power of attorney, my Agent is authorized to exercise all rights, fulfill all obligations and satisfy all debts regarding my interests in any community property or property that is otherwise jointly owned by me and my Agent. Power with Respect to Retirement Assets and Insurance Contracts. ___________ . My Agent is authorized to manage any interest that I may have in any retirement asset or insurance contract, which shall include any interest that I may have in any qualified retirement plan, annuity or account, such as any pension, annuity or other plan or account governed by ERISA, CSRS or FERS, any IRA, SEP-IRA or SIMPLE IRA, any tax-sheltered annuity, any deferred compensation plan, any modified endowment contract or any medical savings account. The authority to manage any such interest shall include making any elections or undertaking other acts which are required under applicable law to create, maintain or enhance any tax-advantaged status of my interest. The authority shall include authorizing the timing and amount of any distributions from the retirement asset or insurance contract. The authority shall include authorizing payment for premiums for any insurance contract. However, this authority is limited to the extent that my Agent does not have the authority to change the name of any beneficiary in any retirement asset or insurance contract. Power with Respect to Qualification for Medicaid or Other Governmental Benefits . My Agent is authorized to utilize all lawful means and methods to recover such assets and rights, qualify me for and claim benefits provided by any governmental agency or body, to include Medicaid, Medicare, Supplemental Social Security, and Social Security Disability Insurance. This authority includes converting my assets into assets that do not disqualify me from receiving such benefits and to make gifts in accordance with the gifting authority granted elsewhere in this instrument My Agent is directed to consider all rules, regulations and statutes regarding disqualification or other adverse actions that may result from such gifting. Power to Create, Fund, Amend, and Terminate Trusts. . My Agent is authorized to execute and amend a revocable trust agreement, to transfer property to the trustee, to withdraw or receive income or corpus of any trust that has been created by me or for my benefit, change or designate a trustee and to exercise any right that I may now have or later obtain in any such trust. Power to Make Gifts.__ . My Agent is authorized to make gifts, to include the forgiveness of indebtedness, to my spouse, my children and descendants and to the spouses of my children and descendants, to include my Agent, in whatever amounts and for whatever purposes as my Agent deems appropriate. My Agent may also make gifts to any tax-exempt charitable organization recognized under Internal Revenue Code ("IRC") Sections 170(c) or 501(c)(3) and to those persons named as beneficiaries in the Principal’s most recent will or trust, life insurance policy, retirement benefits or payable on death designation. As to any donee, these amounts shall not exceed the largest amount which then qualifies for the annual exclusion allowed for federal gift tax purposes as set forth in Section 2503 of the IRC. The authority to make gifts is non-cumulative and shall lapse at the end of each calendar year. All gifts may be made outright, in trust or to any guardian, conservator or custodian of an eligible donee. Gifts are not required to be in equal amounts and are not required to be made to all eligible donees. ARTICLE III Benefits Received by Agent._________. It is my intention that my Agent be reasonably compensated for the services rendered on my behalf and be reimbursed for any expenses paid by the Agent which were incurred on my behalf. Reasonable compensation shall not exceed the hourly wage or salary equivalent which the Agent customarily receives in his or her regular employment. Reimbursement shall include, but is not limited to, monies paid for medications (whether prescribed or purchased over the counter), medical co-payments, fees for medical, nursing and caregiver services or laboratory work, household or personal incidentals, automobile maintenance and repair, lawn services or landscaping, fees for professional services (such as an attorney, CPA or financial advisor), reasonable travel or lodging costs in performance of the duties created by this power of attorney, maintenance and repair of my residence and care of my pets. Benefits authorized to be received by my Agent shall include any imputed rent deemed to exist due to any arrangement, agreement or understanding between my Agent and I which allows my Agent to live rent-free in my residence or other property owned by me. Waiver for Acts of Omission. My Agent, if acting in good faith, is hereby released and discharged from any and all civil liability and from all claims or demands made by me or my heirs and assigns arising out of acts or omissions of my Agents, except for willful misconduct and gross negligence. Severability. If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such part shall be ineffective to the extent of such invalidity only, without in any way affecting the remaining parts of such provision or the remaining provision or the remaining provision of this instrument. Governing Law. This instrument shall be governed by the laws of the State of Arizona in all respects, including its validity, construction, interpretation, and termination. Effect of Other Jurisdictions. To the extent permitted by law, this instrument shall be applicable to all property of mine, real, personal, intangible, and mixed, wherever and in whatever State of the United States or foreign country the situs of the property is at any time located. This includes all property now owned by me or subsequently acquired by me or for me by my Agent. Separation or Divorce. If my spouse has been appointed my Agent or Alternate Agent, and my spouse and I are later legally separated or divorced, or in the event that such an action is now pending, such legal separation, divorce, or pending actions shall automatically and without notice remove my spouse as Agent or Alternate Agent.
Power to Sue Third Parties Who Fail to Act Pursuant to Power of Attorney. If any third party (including stock transfer agents, title insurance companies, banks, credit unions, and savings and loan associations) with whom my Agent seeks to transact refuses to recognize my Agent’s authority to act on my behalf pursuant to this Power of Attorney, I authorized my agent to sue and recover from such third party all resulting damages, costs, expenses, and attorney’s fees that are incurred because of such failure to act. The costs, expenses, and attorney’s fees incurred in bringing such action shall be charged against my general assets, to the extent that they are not recovered from said third party. I, the Principal, execute this document intending it to be effective on the date that it is signed. I understand that a) this document gives my Agent serious powers over me and my assets, b) the powers continue after I become incapacitated or disabled and c) I can revoke and cancel this document at any time and for any reason or no reason. Further, I, the Principal, sign my name to this Power of Attorney on the date indicated below and being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes expressed in the power of attorney and that I am eighteen years of age or older, of sound mind and under no constraint or undue influence. DATED this d-t. ___________________________
N-1, Principal I, (Paralegal’s Name), the witness, sign my name to the foregoing power of attorney being first duly sworn and do declare to the undersigned authority that the Principal signs and executes this instrument as his/her power of attorney and that he/she signs it willingly, or willingly directs another to sign for him/her, and that I, in the presence and hearing of the Principal, sign this power of attorney as witness to the Principal’s signing and that to the best of my knowledge, the Principal is eighteen years of age or older, of sound mind and under no constraint or undue influence.
Paralegal’s Name, Witness STATE OF ARIZONA ) ) ss. County of Maricopa ) Subscribed, sworn to and acknowledged before me by N-1, the Principal, and subscribed and sworn to before me by (Paralegal’s Name), the witness, this d-t.
Attorney’s Name Attorney at Law/ Notary Public
DURABLE POWER OF ATTORNEY
PRINCIPAL: N-1
AGENT: N-2 Address
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DURABLE
POWER OF ATTORNEY FOR
HEALTH CARE DECISIONS FOR
N-1 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, “health 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- Spouse 2.
N-3- 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,
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 the
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 acting in a decision-making
capacity. DATED THIS d-t.
By:
N-1, 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.
Attorney Name,
Witness
Paralegal, Witness STATE OF
ARIZONA
)
) ss. COUNTY OF
MARICOPA )
Subscribed, sworn
to, and acknowledged before me by N-1 and subscribed and sworn to
before me by Paralegal Name, a witness, this d-t.
Attorney Name
Attorney at
Law/Notary Public STATE OF
ARIZONA
)
) ss. COUNTY OF
MARICOPA )
Subscribed, sworn
to, and acknowledged before me by N-1 and subscribed and sworn to
before me by Attorney Name, a witness, this d-t.
Paralegal Name, Notary Public
DURABLE POWER
OF ATTORNEY FOR HEALTH CARE DECISIONS PRINCIPAL: N-1 N1-ad N2-tl AGENT: N-2 N2-ad N2-tl
FIRST ALTERNATE
AGENT: N-3 N3-ad N3-tr SECOND ALTERNATE
AGENT: N-4
N4-ad N4-tl c:\estate
planning10\f-l\ hc-poa-lw kit -
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