36-3224. Sample health care power of
attorney


Any writing that meets the requirements of section 36-3221 may be used to create a
health care power of attorney. The following form is offered as a sample only and does
not prevent a person from using other language or another form:


1. Health Care Power of Attorney


I, ___________________________________, as principal, designate
______________________ as my agent for all matters relating to my health care,
including, without limitation, full power to give or refuse consent to all
medical, surgical, hospital and related health care. This power of attorney is
effective on my inability to make or communicate health care decisions. All of
my agent's actions under this power during any period when I am unable to make
or communicate health care decisions or when there is uncertainty whether I am
dead or alive have the same effect on my heirs, devisees and personal
representatives as if I were alive, competent and acting for myself.


If my agent is unwilling or unable to serve or continue to serve, I hereby
appoint ____________________ as my agent.


I have _____ I have not _____ completed and attached a living will for
purposes of providing specific direction to my agent in situations that may
occur during any period when I am unable to make or communicate health care
decisions or after my death. My agent is directed to implement those choices I
have initialed in the living will.


I have _____ I have not _____ completed a prehospital medical care directive
pursuant to section 36-3251, Arizona Revised Statutes.


This health care directive is made under section 36-3221, Arizona Revised
Statutes, and continues in effect for all who may rely on it except those to
whom I have given notice of its revocation.


______________________________


Signature of Principal


Witness: _____________________ Date: _____________________


_______________________________ Time: _____________________


Address: _____________________ ____________________________


_______________________________ ____________________________


Address of Agent


Witness: _____________________ ____________________________



 _______________________________ Telephone of Agent

Address: _____________________


_______________________________


(Note: This document may be notarized instead of being witnessed.)


2. Autopsy (under Arizona law an autopsy may be required)


If you wish to do so, reflect your desires below:


_______ 1. I do not consent to an autopsy.


_______ 2. I consent to an autopsy.


_______ 3. My agent may give consent to or refuse an autopsy.


3. Organ Donation (Optional)


(Under Arizona law, you may make a gift of all or part of your body to a 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 body pursuant to law. Note: The donation elections you make in this
health care power of attorney survive your death.)


If any of the statements below reflects your desire, initial on the line next
to that statement. You do not have to initial any of the statements.


If you do not check any of the statements, your agent and your family will
have the authority to make a gift of all or part of your body under Arizona
law.


_______ I do not want to make an organ or tissue donation and I do not want my
agent or family to do so.


_______ I have already signed a written agreement or donor card regarding
organ and tissue donation with the following individual or institution:
___________________________________


_______ Pursuant to Arizona law, I hereby give, effective on my death:


[] Any needed organ or parts.


[] The following part or organs listed:


_____________________________________________________


_____________________________________________________


_____________________________________________________


for (check one):


[] Any legally authorized purpose.


[] Transplant or therapeutic purposes only.


4. Physician Affidavit (Optional)


(Before initialing any choices above you may wish to ask questions of your
physician regarding a particular treatment alternative. If you do speak with
your physician it is a good idea to ask your physician to complete this
affidavit and keep a copy for his file.)


I, Dr. ___________________________ have reviewed this guidance document and
have discussed with _______________ any questions regarding the probable
medical consequences of the treatment choices provided above. This discussion
with the principal occurred on _________________.


(date)


I have agreed to comply with the provisions of this directive.


___________________________


Signature of Physician


5. Living Will (Optional. Section 36-3262, Arizona Revised Statutes,
has a sample living will.)


6. Funeral and Burial Disposition (Optional)


My agent has authority to carry out all matters relating to my funeral and
burial disposition wishes in accordance with this power of attorney, which is
effective upon my death.


My wishes are reflected below:


_______ Upon my death, I direct my body to be buried. (as opposed to cremated)


_______ Upon my death, I direct my body to be buried in
___________________________________________________. (Optional directive)


_______ Upon my death, I direct my body to be cremated.


_______ Upon my death, I direct my body to be cremated, with my ashes to
be_______________________________________. (Optional directive)


_______ My agent may make all funeral and burial disposition decisions.
(Optional directive)