- Durable Power Of Attorney For Healthcare And Finances
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- Durable Power Of Attorney
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Durable Power Of Attorney For Healthcare And Finances – An Arizona medical power of attorney is a document that allows a family member or spouse to handle another person’s medical needs. A power of attorney is written by the principal if they cannot speak to the medical staff themselves. This is commonly due to dementia, Alzheimer’s disease, or the result of recent surgery. A medical power of attorney can be revoked at any time by the principal completing a Revocation Form.
Once the Principal has assembled and organized the additional or additional paperwork, open the form here on this page (below the image). Keep this form for safekeeping. You can use it on the screen with the appropriate software.
Durable Power Of Attorney For Healthcare And Finances
2 – The Principal Authority will need to be identified in the first part by entering the requested information
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Several labeled lines have been provided for this purpose. Enter the Principal’s name in the “My name” line. Then, in the line “My address”, enter our Principal Address.
On the right-hand side there will be a line column asking for the principal’s Age, Date of Birth, and Phone Number. Use the lines labeled “My Age,” “My Date of Birth,” and “My Phone Number” to report this information.
The second part will also have some blank lines asking for information, but these will refer to the Agent or Surrogate. That is, the entity that will have Medical Decision Making Power regarding the Principal’s Health. First, use the “Name” and “Address” lines to state the Surrogate Agent’s full name and record the Surrogate Agent’s Address.
The blank line column on the right, in Section 2, should have the Surrogate Agent’s Contact Information. Enter the Surrogate Agent’s Home Phone Number, Work Phone Number, and Cell Phone Number in the blank lines labeled “Home Phone”, “Work Phone”, and “Cell Phone”
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This section will also allow an Alternate Representative to be selected and reported by the Principal. This party will step into the responsibility of the Surrogate Agent if he or she is unable, is not, or is no longer permitted to use the Principal’s Medical Decision Making Power. Below the statement beginning with “I appoint the following person to do…,” use the blank lines labeled “Name,” “Address,” “Home Phone,” “Work Phone,” and “Cell Phone” to document the Representative’s Identity Alternatively. , Home Address, and Contact Information.
The Third Section will specify the various actions and decisions that may be influenced by the Surrogate Agent as a result of this document. Make sure the Principal understands this statement and all related provisions. After this task is completed, the Principal must document the limitations, restrictions, conditions, or specifications in the space below the statement beginning with “I do not want my representative…” in Section 4.
Item 5 provides a section where the Principal can divulge his preferences in terms of having an autopsy after death. Find the title “5. My special wishes about the autopsy.” Three statements with blank lines will be provided under the “Notes” box. If the Principal does not consent to the autopsy, he must start or mark a blank line before the words “After death I do NOT consent. ..”
If the Principal does not object to the autopsy, he must mark or start a blank line before the second statement.
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The Principal may choose to authorize the Agent/Surrogate to make these decisions. If so, he should mark or start a third statement.
Section 6, “My special wishes regarding organ donation …,” presents two simple statements. If the Principal does not want to make an Anatomical Gift (i.e. Organ Donation), he should initial or mark Option A. If the Principal wants to make an Anatomical Gift, he should mark Option “B”, then proceed to the question below to redefine the nature of the anatomical Gift which will be done.
If the Principal has indicated that he wishes to make an Anatomy Prize, then Item 1 will allow some specification to be made. Principals can choose to donate their Whole Body by filling in bubble “a”, Any Parts/Organs Needed by filling in bubble “b”, or specific parts/organs by filling in bubble “c”. Note: If you choose “c,” the specific part / organ must be specified in the numbered line below this option.
The next item will allow the Head of School to quickly name the purpose of anatomical Donations can be made (if any). If the principal authorizes the Anatomy Gift to be made for all legal purposes, the first bubble must be marked or filled. If the Principal will only approve Anatomy Gifts for Transplants or Therapeutic Purposes, bubble “b” will need to be filled. If the Principal only authorizes Anatomy Prizes for Research Purposes, bubble “d” must be filled. Principals may have other specific Purposes for Anatomy Gifts. If so, select “d,” and enter the Approved Purpose on the blank line.
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The Principal may also have a preference as to where the Anatomy Gift may be made. In Item 3, the Principal can name the Organization or Individual to whom the Anatomy Prize can be made. Fill in bubble “a” if the Principal has signed a written agreement with the receiving individual or institution and document the Identity of this entity in the blank line provided. If the Principal does not have such an agreement but wishes the Anatomical Gift to be made to a specific entity, then mark the bubble “b” and record the Name of the Entity in the blank line provided. The Principal may choose to allow a Surrogate or Representative to make this decision by filling in bubble “c”.
If the Principal has preferences or instructions about “Funeral and Burial Disposition” arrangements, they can be made in Section 7. This section will contain a list of items with a blank line before each of them. The Principal must initial or mark the statement.
If the Principal wants the body to be buried, then he should start the first statement.
If the Principal wants the body to be buried and intends for special instructions to be followed, then he or she should start the second statement. There will be a blank line in the second statement where the Principal should indicate what the specific instructions are.
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The principal also has the option to direct for a cremation. If so, he should begin the third statement.
If the Principal prefers cremation and has instructions about this, then he should start the fourth statement.
The Principal may elect to have the Surrogate Agent make such decisions. If so, then he should start the fifth statement. This will empower the Agent to make funeral/burial/cremation decisions on behalf of the Principal.
If the Principal has signed a Living Will, this should be attached to this form and indicated. Look for Section 8 titled “About Living Wills.” If the Principal has signed and attached a Living Will, he/she must initial Option “A”, then attach a complete and completed Living Will. If this is not the case, the Principal must indicate that he has not signed the Living Will and therefore, no such document is attached by starting Option “B”.
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If the Principal has signed a Prehospital Medical Care Directive or a Do Not Resuscitate Directive on Paper with a Person background, then he must attach this document with the initial Option “A”. If not, then he should choose the initial Option “B”.
If the Principal authorizes the Agent to have the same rights regarding the disclosure and use of the Principal’s Health/Medical information pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, then he must start a blank line next to that statement. in Section 10. If not, then he or she must leave this statement marked.
Look for the heading “Signature or Verification”. Item “A” requires the Principal to sign a blank line labeled “My Signature.” When completed, the Principal must enter the Date he signed this document in the blank line labeled “Date”.
Item B has been provided in cases where the Principal cannot sign this document. Here, the Witness who has received the order to explain this document can Sign in to confirm its authenticity. If this is the case, such Witness should read the Item B Statement, then Print their Name on the “Witness Name” line and enter their Name on the “Signature” line. The date of this Signature shall be entered by the Signatory Party in the blank line after the word “Date”.
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The signing of this document can be verified through an Adult Witness or Notary Public. Each will have a different area under the heading “Witness or Notary Signature”. If the signing of this document is to be verified by a Witness, the Witness must Print and Sign his Name. The Date of Signature must be reported in the “Date” line and the Address of the Witness must be entered with a blank.
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