The following free Health Care Power of Attorney is a thorough agreement. This agreement and contract is being provided for information and research purposes only, however it is a valid legal contract and agreement. Always consult an Attorney or Lawyer.
This document should be used in conjunction with a Last Will and Testament, Living Will, Durable Power of Attorney and a Trust. All these documents can be found in the Trusts and Estate Section of this website. This Agreement can apply in most states including California, New York, Florida, Nevada and others. Help improve this agreement by leaving a comment.
I, ____________________, being a resident of ____________________, ____________________ County, Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud, or undue influence of any person, do make, publish, and declare this to be my Health Care Power of Attorney to be used whenever I cannot make or communicate my own health care decisions because of mental or physical illness, injury, disability or incapacity.
I. Designation of Attorney-in-Fact:
I, ____________________, appoint the following person as my Attorney-In-Fact to make health care decisions for me as authorized in this document.
II. Designation of Alternate Agents if Above-Named Agent Cannot Serve. If the person named as my agent is unwilling, or unable to act as my agent, or cannot be reached after reasonable efforts have been made, then I appoint the following persons, in the order of priority set forth, to serve:
III. Direction as to when my Attorney-in-Fact may make my Health Care Decisions: My Attorney-in-Fact is directed to make health care decisions for me WHENEVER I CANNOT MAKE OR COMMUNICATE MY OWN HEALTH CARE DECISIONS BECAUSE OF MENTAL OR PHYSICAL ILLNESS, INJURY, DISABILITY OR INCAPACITY.
IV. Health Care Authority Granted to Attorney-in-Fact:
I give my attorney-in-fact complete authority to make decisions regarding my health care, including the following powers: (a) to consent to giving, withholding, or stopping any health care, treatment, service or diagnostic procedure, and sign forms necessary to carry out these decisions; (b) to talk with health care personnel and review my medical records, as well as to receive copies; (c) to visit me as needed; (d) to retain and dismiss health care providers; (e) to admit me to, or discharge me from (even against medical advice), any health care institution, nurse home, assisted living facility or other facility or program.
V. Mental Health Care Authority Granted to Attorney-in-Fact:
My agent is designated for all matters relating to my mental health care, including without limitation, full power to give or refuse consent to all medical, surgical, hospital and related mental health care. I want my agent to make decisions concerning my mental health care treatment that are consistent with my wishes as expressed in this document, or, if not specifically expressed, as are otherwise known to my agent.
If my wishes are unknown to my agent, I want my agent to make decisions regarding my mental health care that are consistent with what my agent, in good faith, believes to be in my best interests. My agent is also authorized to receive information regarding proposed mental health treatment and to receive and consent to disclosure of any medical records relating to that treatment.
This declaration allows me to state my wishes regarding mental health care treatment, including medications, admission to and retention to and retention in a health care facility for mental health care treatment and outpatient services.
VI. Instructions to My Attorney-in-Fact on How to Make Health Care Decisions for Me. My Attorney-in-Fact shall make health care and mental health care decisions as I direct in this document and as I make known to him or to her in some other way. My Attorney-in-Fact should attempt to discuss health care and mental health care choices with me if I am able to communicate in any manner, and should inform me of any decisions if I am unable to communicate, but may be able to understand. If I have not expressed a choice about the health care or mental health care in question, I direct that my Attorney-in-Fact decide based upon his or her knowledge of my values. If my Attorney-in-Fact does not know what I would want, or my values, then I want my Attorney-in-Fact to decide based upon what my Attorney-in-Fact believes to be in my best interest.
VII. Effect on other Advance Directives:
I revoke any prior Power of Attorney for Health Care made in Arizona, and intend this document to take precedence in Arizona over any Power of Attorney for Health Care I may have executed in another state.
VIII. Revocation of this Document:
This Power of Attorney for Health Care can be revoked by: (1) written statement; (2) orally, by notifying the Attorney-in-Fact or a health care provider; or (3) by any other specific expression of intention to revoke this document or remove the Attorney-in-Fact.
IX. New HIPAA Regulations Require Amendment. A recent federal regulations known as the Health Insurance Portability and Accountability Act (HIPAA) regarding disclosure of individually identifiable health information necessitated the addition of a special release and consent authority to all healthcare providers before medical information will be released to the Attorney-in-Fact of the patient.
X. HIPAA Release Authority. I instruct that my Attorney-in-Fact be treated as I want to be treated 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, 42 USC 1320d and 45 CFR 160-164.
XI. Legal Consent for Disclosure of Health Care Information. Any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other health care provider, any insurance company, the Medical Information Bureau Inc. or other health care clearinghouse that has provided treatment or services shall give, disclose and release to my designated Attorney-in-Fact, without restriction, identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnoses treatment of HIV / AIDS sexually transmitted diseases, mental illness and drug or alcohol abuse.
XII. Legal Consent for Disclosure of Specific Mental Health Care Information. Any psychologist, psychiatrist, licensed therapist or other healthcare provider involved with diagnoses or therapy or other treatment of me which pertains to my mental health shall give disclose and release to my designated Attorney-in-Fact any and all individually identifiable health information and medical records involving any past present or future mental health condition. This specific authorization includes but is not limited to psychotherapy notes defined by HIPA as “notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session”, as well as medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plans, symptoms, prognosis or progress. My Attorney-in-Fact shall have the same rights of access to these notes as I am entitled to under the provisions of HIPAA and under applicable state law.
XIII. Supersession of Prior Documents and Expiration Event. The authority given my agent in this legal consent form shall supercede any prior agreements that I may have made with my health care providers to restrict access or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider.
XIV. Release and Hold Harmless Provision. In order to induce the disclosing party to disclose the aforesaid private and / protected confidential information, I forever release and hold harmless said disclosing party who relies on this instrument from any liability under confidentiality rules arising from HIPAA as a consequence of said disclosure.
By my signature or mark below I indicate that I understand the purpose and effect of this document.
WARNING TO PERSONS EXECUTING
THIS DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
To the person executing this document:
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. The powers granted by this document are broad and sweeping. If you become incapacitated, the person you designate as your Attorney-in-Fact will have broad powers to make health care decisions for you, subject to the limitations or statements of your desires that you include in this document.
2. The powers in this Durable Power of Attorney for Health Care shall become effective on your incapacitation and will exist for an infinite period of time unless you limited their duration in this document. These powers will exist during your incapacitation.
3. You have the right to revoke or terminate this Durable Power of Attorney at any time.
IN WITNESS WHEREOF, I execute this document intending it become effective on the date hereinabove first stated.
Date Signed ____________________, Principal
This Durable Power of Attorney for Health Care, consisting of 5 pages, including this page and the following page(s), was signed in the presence of us who, at the request and in the presence of Testator and in the presence of each other, have signed the same as witnesses thereto. WE ALSO AFFIRM THAT WE ARE NOT RELATED TO THE TRUSTOR BY BLOOD, MARRIAGE OR ADOPTION AND THAT WE ARE AWARE OF NO INHERITANCE RIGHTS, GIFTS, OR DISTRIBUTIONS THAT WE SHALL RECEIVE FROM TRUSTOR’S WILL OR FROM ANY OTHER SOURCE FROM THE TESTATOR AND ARE NOT PERSONS INVOLVED WITH THE MEDICAL CARE OF THE TESTATOR.
Witness Name (Printed) Witness Address
Witness Name (Printed) Witness Address
ACKNOWLEDGMENT AND VERIFICATION
OF PRINCIPAL AND WITNESSES
STATE OF: ____________________
COUNTY OF: ____________________
On this _______ day of _________________, ________, this instrument was acknowledged before me, a Notary Public, personally appeared the above witnesses known to me or satisfactorily proven to be the person whose names are subscribed to this instrument and acknowledged that they executed the same for the purposes contained therein.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Printed Name: _________________
My Commission Expires: ______________________
Commission # __________________