Arizona Attorney General Life Care Planning Packet

The free Arizona Attorney General forms and my step by step instructions for completing them.

Step by Step Instructions

These instructions walk you through the free Arizona Attorney General Life Care Planning forms, one question at a time, so you can fill them out yourself with confidence.

Important: This page is general information only. It is not legal or medical advice, and it does not tell you which choices to make. Those decisions are yours. I am an Arizona Certified Legal Document Preparer, not an attorney. If you have questions about medical treatments, talk with your doctor. If you need legal advice, talk with an attorney.

Where to Get the Forms

The Arizona Attorney General’s Office provides the forms free of charge:

Online: www.azag.gov/issues/elder-affairs/life-care-planning
By phone: Call the Community Outreach and Education Section at 602‑542‑2123 to request a packet by mail.

The packet includes:

Health Care Power of Attorney: names the person (your “agent”) who makes medical decisions for you if you cannot.
Living Will: states the end of life treatment you do or do not want.
Mental Health Care Power of Attorney: names the person who makes mental health care decisions for you if you cannot.
Prehospital Medical Care Directive (DNR): tells EMTs and first responders not to resuscitate you. It must be signed by your doctor and printed on orange paper.
Registration Agreement: optional. Used only if you want to file copies with the Arizona Healthcare Directives Registry.

You do not have to complete every form. Fill out only the ones that fit your wishes.

Before You Start: Tips for All Forms

Print clearly in blue or black ink, or type into the forms before printing.
Initial where the form asks for initials and check boxes where it asks for checks. Read every choice in a section before you mark one.
Do not leave blanks you were asked to fill. If a line asks you to explain something and you have nothing to add, write “None.”
Choose your agent and alternates carefully. Ask them first whether they are willing to serve, and give them a copy when you are done.
Talk with your doctor and family about your wishes. The forms work best when the people involved already know what you want.

Signing: Witness OR Notary, Not Both

Do not sign any form until your witness or notary is watching you sign. Each form must be signed in front of either one adult witness or a notary public. Do not have both sign.

Your witness or notary cannot be anyone who is:

Under the age of 18
Related to you by blood, adoption, or marriage
Entitled to any part of your estate
Named as your agent or alternate agent
Involved in providing your health care at the time you sign

If you would like to sign in front of a notary, call me to schedule an appointment. Bring a current photo ID and your unsigned forms.

Health Care Power of Attorney

This form names the person you trust to make medical decisions for you if you become unable to make or communicate them yourself.

My Information and Agent Selection. Fill in your own information, then your agent and up to two alternates. The alternates serve only if the person before them is unavailable, unwilling, or unable to act.

Health care decisions I expressly DO NOT AUTHORIZE. List any decisions you do not want your agent to make. If there are none, write “None.” Do not leave it blank.

Autopsy. Initial one box. An autopsy is sometimes required by law, and this choice does not change that. A voluntary autopsy you request may cost money.

Organ Donation (check one box only)

Yes. You choose to donate organs, tissues, and eyes. Under the Yes box, cross out either purpose you do not want: (a) Transplant and Therapy, or (b) Research and Education. Use the blank lines to write any limits on which organs or tissues, or for what purposes.
I’ve already registered. Choose this if you have already signed up as a donor, for example through the state donor registry or on your driver’s license, and you want that decision followed.
Not at this time. Your agent decides for you.
No. You do not want any donation, and you do not want anyone to authorize it on your behalf.

If you have arranged to donate your body to science: Whole body donation is different from organ donation. It is an arrangement you make directly with a body donation program, such as a medical school or research program. Many of these programs need the body intact and may not accept it if organs have already been removed. Before you complete this section:

Contact your body donation program and ask how it wants you to complete the organ donation section.
Use the blank “specific limits” lines to write in your arrangement, for example: “I have arranged whole body donation with [program name]. Please contact them at [phone number].”
Give your agent and family a copy of your program paperwork.

Funeral and Burial Wishes

Initial the choice that fits your wishes, or initial the first box to let your agent make all funeral and burial decisions. If you choose burial or cremation, fill in the blank lines with where you want to be buried or what you want done with your ashes.

If you have arranged to donate your body to science: None of the boxes may fit exactly. Many body donation programs cremate the remains after their studies are finished and may return the ashes to the family. You can write your arrangement on the blank lines, for example: “My body is to be donated to [program name]. After the program is finished, my ashes are to be returned to my family.” Check with your program about what it does with remains.

Do You Have a Living Will?

Initial one box. If you completed the Living Will in this packet, you must attach it to this Health Care Power of Attorney.

Do You Have a POLST (Portable Medical Order)?

A POLST is a medical order that you complete together with your doctor. It is meant for people who are seriously ill or frail and nearing the end of life. It tells medical staff which treatments you want in an emergency. You do not fill it out on your own.

If you and your doctor have completed a POLST, initial the first box and attach a copy.
If not, initial “I have NOT SIGNED a POLST.”

Do You Have a Prehospital Medical Care Directive (DNR)?

This is the orange form described below under Prehospital Medical Care Directive (DNR). It is signed by you and your doctor. Initial the box that matches whether you have one. If you have not completed one, initial “I have NOT SIGNED.”

Physician Affidavit (optional)

If you talk with your doctor about this form, you can ask your doctor to sign here and keep a copy in your medical file. You may leave it blank.

HIPAA Waiver

Initial this line if you want your agent to have the same access to your medical records and health information that you have. Without it, your agent may have trouble getting information from doctors and hospitals.

Signature

Sign and date in front of your witness or notary (see Signing above). The “Witness/Notary Verification” section is only for someone who is physically unable to sign.

Living Will

The Living Will is your written direction to your agent, family, and doctors about end of life treatment. It applies only if you are in a terminal condition, an irreversible coma, or a persistent vegetative state. Ask your doctor if you want those terms explained.

You may initial any combination of paragraphs 1, 2, 3, and 4. If you initial paragraph 5, do not initial any of the others.

Paragraphs 1 and 2: Why They Are Not the Same Question

Many people think these two paragraphs say the same thing. They overlap, but they are different:

Paragraph 1 applies to a terminal condition only. It is a general statement: no life sustaining treatment beyond comfort care that would only delay death. You initial one line.
Paragraph 2 applies to a terminal condition, OR an irreversible coma, OR a persistent vegetative state. It keeps comfort care but lets you refuse specific treatments. You initial the main line, plus each item a, b, or c that you do not want.

The items under paragraph 2 are:

2a. CPR: cardiopulmonary resuscitation, such as drugs, electric shock, and artificial breathing to restart the heart or lungs.
2b. Artificially administered food and fluids: feeding tubes or IV nutrition and hydration.
2c. Being taken to a hospital if at all avoidable: for example, staying at home or in hospice instead.

You may initial paragraph 1, paragraph 2, both, or neither. If you initial paragraph 2, remember to also initial each of a, b, and c that you do not want. Any item you leave blank under paragraph 2 is not refused.

Comfort care means treatment to relieve pain and keep you comfortable without artificially prolonging life. Choosing paragraph 1 or 2 does not mean you refuse comfort care.

Paragraph 3: Pregnancy

This applies only if you could be pregnant at the time. If initialed, life sustaining treatment would continue during a pregnancy if the baby could develop to the point of live birth, no matter what else you chose.

Paragraph 4: Treat Until a Diagnosis Is Made

If initialed, you want all medical care needed to treat your condition until your doctors reasonably conclude your condition is terminal, irreversible and incurable, or a persistent vegetative state. Your other choices apply after that point.

Paragraph 5: Prolong My Life as Long as Possible

If initialed, you want your life prolonged to the greatest extent possible. This is the opposite of paragraphs 1 and 2, so do not initial any other paragraph if you choose 5.

Additional Instructions: Box A or B

Initial A if you are not attaching anything more. Initial B only if you are attaching a separate page of additional instructions, and be sure to attach it.

Signature

Mental Health Care Power of Attorney

This form names the person who makes mental health care decisions for you if you become unable to make them. It is separate from the Health Care Power of Attorney. You may name the same person on both forms or different people.

Who decides you are unable? Only a specialist in neurology or an Arizona licensed psychiatrist or psychologist can make that decision, after evaluating you.

Agent and Alternate. Fill in your agent and one alternate.

Treatments I AUTHORIZE. Initial each power you want your agent to have:

Receiving your mental health records and consenting to their release
Consenting to medications your treating physician recommends
Admitting you to an inpatient or partial psychiatric hospitalization program
Other: write in anything else you want to authorize

Any line you do not initial is a power your agent does not have.

Treatments I expressly DO NOT AUTHORIZE. List anything you do not want. If there is nothing, write “None.”

Revocability. Unlike your other forms, you cannot cancel this one during a time you have been found unable to give informed consent. At all other times you may cancel or change it.

HIPAA Waiver. Initial if you want your agent to have the same access to your mental health records that you have.

Signature. Sign in front of your witness or notary.

Prehospital Medical Care Directive (DNR)

This form tells EMTs, paramedics, and other first responders outside a hospital not to resuscitate you if your heart or breathing stops. It is often called a DNR (Do Not Resuscitate).

How it differs from the Living Will:

The Living Will speaks to your agent, family, and doctors. The DNR speaks to EMTs and first responders.
The Living Will applies only in a terminal condition, irreversible coma, or persistent vegetative state. The DNR applies any time your heart or breathing stops outside a hospital.
The Living Will does not need a doctor’s signature. The DNR must be signed by your doctor or other licensed health care provider.
The Living Will is on regular paper. The DNR must be on orange paper (letter size or wallet size).

Things to know before completing it:

It is not required. It is usually meant for people who are very sick, terminally ill, or extremely weak. Talk with your doctor about whether it is right for you.
It must be printed on orange paper to be valid under Arizona law.
Your doctor or other licensed health care provider must sign it. Bring it to your appointment.
Attach a recent photo or fill in your date of birth, sex, race, eye color, and hair color, so first responders can identify you.
Keep it where first responders will see it, such as on your refrigerator or by your bed.
It applies before you reach a hospital. If you are admitted, the hospital may ask you to complete its own form.

If you cannot communicate and have named a health care agent, your agent may sign it for you.

After You Sign

Keep the originals in a safe place that is easy to reach. Do not lock them in a safe deposit box.
Give copies to your agent and alternates, your doctor, and close family. Keep a list of who has copies so you can update everyone if you make changes.
Take a copy with you if you go to a hospital or other health care facility.
Fill out the wallet card in the packet’s information section and keep it with your driver’s license.
Review your forms from time to time, especially after a move, a marriage or divorce, or a change of agent.

Optional: Arizona Healthcare Directives Registry

The Registry stores copies of your forms electronically so hospitals and first responders can find them. It is free and optional.

Send copies only, never originals. The Registry does not return what you send.
You must include the Registration Agreement. Its signature page must be notarized, even if your forms were signed in front of a witness.
Mail to AZ Healthcare Directives Registry, 2901 N. Central Ave., Ste. 1100, Phoenix, AZ 85012, or email azhdr@contexture.org, or fax 602‑264‑8823.
Processing can take up to three weeks.

Changing Your Forms Later

To make a change, complete new forms and give the new copies to everyone who had the old ones. If you registered, send a new Registration Agreement marked to replace your old documents.

Need a Notary?

Call me to schedule a notary appointment. Bring a current photo ID and your unsigned forms. If you will use a witness instead, your witness must meet the rules in Signing above.

Notary fees may apply.

General information only, not legal or medical advice. A certified legal document preparer is not an attorney and cannot advise you on which choices to make.