Life Care Planning Arizona Attorney General

Summary

LIFE CARE PLANNING
Advance Directives for Making Your Health Care Decisions
Provided by
The Office of Arizona Attorney General,
Mark Brnovich
MAIL FORMS TO:
Arizona Secretary of State
Advance Directive Dept

1700 W. Washington St., 7th Floor
Phoenix, AZ 85007
This packet was last updated 03/2020
WHAT IS LIFE CARE PLANNING AND WHY IS IT SO IMPORTANT?
Life Care Planning is the process of deciding your medical wishes and who you want to carry them
out, in case you are unable to do so. The documents in this packet are meant for you to express your
wishes, whatever they may be, so you receive the treatment you want if you can no longer
communicate. Hopefully, having your wishes clearly stated will help those close to you avoid the pain
of trying to guess what you would or would not want done

Life Care Planning is an important task for all of us, whether young or old, healthy or facing
challenges. None of us knows what life has in store, so taking steps to tell our loved ones of our
wishes can make all the difference on our end of life care. Through increased awareness and access
to information, Arizonans of all ages can make their choices known about who will manage their
medical affairs in the event of an emergency

WHY DOES THE ARIZONA ATTORNEY GENERAL OFFER THESE FORMS?
The Arizona Attorney General’s Office wants to make sure that all Arizonans have access to these
free legal documents, all of which are in line with Arizona Law. The Attorney General’s Office is just
one of several places to get forms and information on life care planning. The Attorney General's
Office is not recommending any particular choices but does urge you to think about these choices,
discuss them with your loved ones, and complete the right documents for your situation

The primary role of the Attorney General’s Office is to provide legal representation to the State of
Arizona, its agencies, and State officials acting in their official capacities. The Office cannot give legal
advice or represent private citizens on personal legal matters. If you need help with a personal legal
matter—such as filing a lawsuit, creating a will, or defending against a criminal charge—you may
want to contact a private attorney

TALKING WITH OTHERS ABOUT YOUR WISHES
You should consider the people that you can begin your life care planning conversations with. Your
medical care is about you - start the conversations with those who can help you consider what
medical treatments you may or may not want if you become incapacitated, or as you approach the
end of your life

 Your Health Care Agent (the person you select to make health care decisions for
you)
 Your Spouse, Children, Other Relatives, and Close Friends
 Your Doctor, Clergyperson and Others
Life Care Planning: Information Office of the Attorney General of Arizona,
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DOCUMENTS INCLUDED IN THIS PACKET
 Life Care Planning Checklist
o This document lists out all the forms in the packet so that you can check off which ones
you have completed. If you wish to register your documents with the Arizona Health
Care Directives Registry, the checklist will let you know which forms are accepted

 Health Care Power of Attorney
o This form allows you to select a person to make future medical decisions for you if you
become too ill to communicate or cannot make those decisions for yourself

 Living Will
o This form allows you to list out the type of medical treatments you do or do not want for
your end of life care. It should go with your Health Care Power of Attorney form so your
agent knows your wishes

 Mental Health Care Power of Attorney
o This form allows you to select a person to make future mental health care decisions for
you in case you become incapable of making those decisions for yourself

 Prehospital Medical Care Directives (Do Not Resuscitate)
o This form needs to be on orange paper and should be signed by you and your doctor. It
informs emergency medical technicians (EMTs) or first responders not to resuscitate
you. Sometimes this is called a DNR – Do Not Resuscitate. Please note this is valid
prior to going to a hospital, if admitted to a hospital they may require you to fill out
another form for their hospital

 Registration Agreement
o If you would like to register your documents with the Arizona Health Care Directives
Registry, you MUST fill out this form and submit it with your documents

WHAT DOES THE LAW SAY?
If you are interested in the laws written about the forms in this packet you can look them up at
www.azleg.gov/arstitle/
 Health Care Power of Attorney: Arizona Revised Statutes §§ 36-3221 et seq

 Health Care Directives: Arizona Revised Statutes §§ 36-3201 et seq

 Agents or Surrogate Decision-Makers: Arizona Revised Statutes §§ 36-3231 et seq
 Living Will: Arizona Revised Statutes §§ 36-3201 et seq AND §§ 36-3261 et seq

 Mental Health Care Power of Attorney: Arizona Revised Statutes §§ 36-3201 et seq AND
§§ 36-3281 et seq

 Prehospital Medical Care Directives (Do Not Resuscitate): Arizona Revised Statutes § 36-3251

Life Care Planning: Information Office of the Attorney General of Arizona,
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WHAT TO DO WITH THESE DOCUMENTS IN 4 STEPS
Step 1: Fill out all forms that apply to you and express your wishes for your end of life care

Read through the documents carefully to select choices that are best suited to your wishes. Each
document will need to be notarized OR witnessed. DO NOT have the documents signed by both, just
pick one. If you do not know a notary or cannot pay for one a witness is legally accepted

Witnesses or Notary Public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
Step 2: Keep the originals in a safe place that is easily accessible

It is important to review your documents from time to time. Give copies to the person you choose as
your agent, as well as your doctor and anyone else who may be contacted about your wishes, such
as family members and close friends. Keep a few extra copies and be sure to take one with you if you
go to a hospital or other health care provider

Step 3: Register your documents on the Arizona Health Care Directives Registry. (Optional)
Send copies of the documents as well as the registration form to the Secretary of State’s Office. The
address is on the cover of this packet and below

Arizona Secretary of State
Advanced Directive Dept

1700 West Washington, 7the Floor
Phoenix, AZ 85007
The purpose of registering Life Care Planning forms is to create a centralized location where your
relatives, first responders, a hospital, or other health care facility can access the forms if they are not
readily available

Step 4 – If Needed: Replacing Existing Directives

If you would like to make changes to your existing documents, you will need to complete any forms
that are affected by that change, i.e. change of address, wishes, or agent. It is important that you
have a list of people with copies of your documents so that you can send them all an updated version
if needed or a letter revoking the forms. The state will accept the most recent version of your
documents

If you have registered your documents with the Registry, you will need to fill out another registration
form and indicate that you are replacing or revoking your existing documents in the Registry

Life Care Planning: Information Office of the Attorney General of Arizona,
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LIFE CARE PLANNING IN OTHER STATES
 If you have advance directives from another state, district, or territory of the US, Arizona
Revised Statutes §§ 36-3208 et seq says it is “valid in this state if it was valid in the place
where and at the time when it was adopted and only to the extent that it does not conflict with
the criminal laws of this state.”
 If you have Arizona advance directives, you will need to check with the Attorney General’s
Office in the other state to find out if they accept Arizona’s documents

FREQUENTLY ASKED QUESTIONS:
1. Where can I find these free forms?
• You can get copies of this Life Care Planning packet and the individual forms on the
Attorney General’s website at https://www.azag.gov/seniors/life-care-planning, or by calling
the Community Outreach and Education Section at 602-542-2123

2. If I do not fill out these forms who will make medical decisions for me?
• If you did not leave a Health Care Power of Attorney and there is no court appointed
guardian, health care providers will contact the following people, in this order, who will have
the authority to make health care decisions for you

• These people are called "surrogates."
1. Your spouse, unless you and your spouse are legally separated

2. Your adult child. If there is more than one adult child, the health care providers will
seek the consent of a majority of the children who are available for consultation

3. Your parent

4. Your domestic partner if no other person has assumed any financial responsibility
for you

5. Your brother or sister

6. Your close friend

3. Should I complete a Do Not Resuscitate "DNR" Form?
• If you are healthy and strong, you may not wish to complete a DNR. You can express your
wishes about how you want to be cared for should you become seriously ill without
completing a DNR. DNRs are most appropriate for people who would probably not do well
with CPR (cardiopulmonary resuscitation) because they are very sick, terminally ill or
otherwise extremely weak. In any case, you will need to discuss the DNR with your doctor,
who will also need to sign the form

4. At what age should I think about filling out these documents?
• Now, so long as you are at least 18 years of age. It is never too early to be prepared

Life Care Planning: Information Office of the Attorney General of Arizona,
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5. Will I need a lawyer to fill out these forms?
• No. You do not need a lawyer’s help to fill out these documents, but you may wish to
consult with a lawyer if you need advice. If you need to find an attorney, you can reach out
to these legal services for help:
• Arizona State Bar
• (602) 252-4804 or www.azbar.org
For help finding an attorney in your budget, area, and skill in the type of help needed

• 24-hour Senior HELP LINE
• Within Maricopa County - (602) 264-HELP / (602) 264-4357
• Outside Maricopa County – toll free - 1-888-264-2258

There are Area Agency on Aging regional offices designated to serve each Arizona county

See your local telephone book for the closest regional office or go to www.des.az.gov and
search Area Agency on Aging for locations

• Elder Law Hotline
• 1-800-231-5441
Free legal advice, information, and referrals provided o Arizona residents 60 years of age
or older, or to family members calling on behalf of a senior. Attorneys do not provide
services in criminal matters, and do not represent clients in court proceedings. They give
advice, information, and referrals on a wide variety of legal matters important to seniors

Funded by the Arizona Supreme Court and operated by Southern Arizona Legal Aid, Inc

WALLET-SIZED NOTICE:
Complete and cut out the notice below. Keep it in your wallet with your driver’s license and
insurance cards so that law enforcement and medical personnel will know who to contact for
copies of your advanced directives

NOTICE IN CASE OF ACCIDENT OR
EMERGENCY:
My Name:
Date:
I have signed the following forms: (check)
□ Health Care Power of Attorney
□ Living Will
□ Mental Health Care Power of Attorney
□ Prehospital Medical Directive (Do Not Resuscitate)
Please contact the following for copies:
Name:
Telephone:
Life Care Planning: Information Office of the Attorney General of Arizona,
Updated 03/2020 Mark Brnovich 6 of 6
LIFE CARE PLANNING
CHECKLIST
 Registration Agreement
• This form HAS to be included if you want to register ANY forms

 Health Care Power of Attorney
 Living Will
 Mental Health Care Power of Attorney
 Prehospital Medical Care Directive (Do Not Resuscitate)
To register your completed documents,
make photo copies and send the copies to:
Arizona Secretary of State
Attn: Advance Directive Dept

1700 W. Washington Street, 7th Floor
Phoenix, AZ 85007
Arizona Health Care Directives Registry
ARIZONA SECRETARY OF STATE
1700 W. Washington Street, 7th Floor, Phoenix, AZ 85007-2888
(602) 542-6187
(800) 458-5842 (within Arizona)
Website: www.azsos.gov
FOR OFFICE USE ONLY - REV. 01/07/19
REGISTRATION AGREEMENT
About this agreement: How to complete this form:
This agreement shall be used for the registration of a
Read this agreement carefully, and fill in all blank spaces
Health Care Directive in the State of Arizona under the authority of
Attach a copy of your witnessed or notarized Health Care
A.R.S. § 36-3291 - 3297 Directive to this Agreement

DO NOT send your original Health Care Directive Form
This form/agreement must be written legibly or computer generated.
Sign and date this Agreement
For your convenience, this form has been designed to be filled out
Return by mail to:
and printed online at the website referenced above. Arizona Secretary of State
1700 W. Washington Street, 7th Fl., Phoenix, AZ 85007
Fees: None Return in person: Tucson: 400 W. Congress, Ste. 141
Processing time-frame: three weeks Phoenix: 1700 W. Washington, Ste. 220
Last Name First Name Middle Name
Address
City State Zip
Phone Birth Date (month/day/year) Last 4 digits of Social Security Number
Printed name as you want it listed on your membership card
Address to return documents and wallet card (IF DIFFERENT FROM ADDRESS ABOVE)
Name
Address
City State Zip
I want to:
 Store a health care directive(s) in the Registry
 Replace a health care directive(s) now in the Registry with a new one
 Add an additional document to my currently stored directive(s)
 Remove my health care directive(s) from the Registry
 Request a replacement wallet card (no change to health care directive(s) in Registry)
 Change Registration Agreement information (such as new a address)
You must complete and sign the Agreement on Page 2 of this form

¶ADÊÎ!ÊÄ AD0001
Page 1 of 2
Arizona Health Care Directives Registry
ARIZONA SECRETARY OF STATE
1700 W. Washington Street, 7th Floor, Phoenix, AZ 85007-2888
(602) 542-6187
(800) 458-5842 (within Arizona)
Website: www.azsos.gov
FOR OFFICE USE ONLY - REV. 01/07/19
REGISTRATION AGREEMENT
I am providing this personal information, along with a copy of my advance directive, with the
understanding that this information will be stored in the Arizona Health Care Directive Registry

I certify that the advance directive that accompanies this Agreement is my currently effective advance
directive, and was duly executed, witnessed and acknowledged in accordance with the laws of the
State of Arizona

I understand this authorization is voluntary. This authorization to store my advance directive in the
Arizona Health Care Directives Registry will remain in force until revoked by me. I understand that I
may revoke this authorization at any time by giving written notice of my revocation to the Contact
Office listed below. I understand that revocation of this authorization will NOT affect any action you
took in reliance on this authorization before you received my written notice of revocation

Contact Office: Office of the Arizona Secretary of State
Telephone: 602-542-6187 E-mail: [email protected]
Address: 1700 W. Washington Street, 7th Floor, Phoenix, AZ, 85007
Your registration form will be processed within three (3) weeks. You will receive further information in
the mail. In order to complete the registration of your health care directive(s) you are required to reply
to the letter that you will receive

For further assistance please contact the Arizona Secretary of State at (602) 542-6187 or visit us
online at: www.azsos.gov
Signature of person completing this agreement Date
Printed Name
¶ADÊÎ"!Ä
AD0002
Page 2 of 2
HEALTH CARE POWER OF ATTORNEY
Instructions and Information
GENERAL INSTRUCTIONS: Use this form if you want to select a person, called an “agent”, to make
future health care decisions for you so that if you become too ill or cannot make those decisions for
yourself the person you choose and trust can make medical decisions for you. Be sure you
understand the importance of this document. It is a good idea to talk to your doctor and loved ones if
you have questions about the type of health care you do or do not want

AUTOPSY CHOICE: If there is no legal reason to require an autopsy, you can decide if you want one
done when you die, or whether you want your agent to choose for you. There is usually a charge for
voluntary autopsies. You can help your family and loved ones by making your preferences on this
topic clear. For additional information on autopsies please review Arizona Revised Statutes §§ 11-
591 and 11-597

ORGAN DONATION CHOICE (OPTIONAL): You can determine if you want to donate organs or
tissues, and if you do, what organs or tissues you want to donate, for what purposes, and to what
organizations. You also have the option of whole-body donation for research purposes. You can also
choose to have your agent decide. For additional information on Organ Donation, please review
Arizona Revised Statutes §§ Title 36, Chapter 7, Article 3 for the laws that pertain to it

FUNERAL AND BURIAL CHOICE (OPTIONAL): You can determine, your funeral and burial
choices in this form. You can select if, upon your death, you would like to be buried and where, or if
you would like to be cremated and where your ashes will go, or you can select your agent to make
that choice

If you fill out this form, make sure you DO NOT SIGN UNTIL your witness or a notary public is
present to watch you sign it

PLEASE NOTE: At least one adult witness, not to include the proxy if there is one, OR a notary public
must witness you signing this document

DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one, a witness is legally accepted

Witnesses or notary public CANNOT be anyone who is:
(a) under the age of 18
(b) related to you by blood, adoption, or marriage
(c) entitled to any part of your estate
(d) appointed as your agent
(e) involved in providing your health care at the time this form is signed
Life Care Planning: Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 03/2020 Mark Brnovich 1 of 5
OFFICE OF THE ARIZONA ATTORNEY GENERAL
MARK BRNOVICH
Health Care Power of Attorney
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Selection of my health care power of attorney and alternate:
I choose the following person to act as my agent to make health care decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: _________________________
____________________________ Cell Phone: __________________________
I choose the following person to act as an alternate to make health care decisions for me if my first
agent is unavailable, unwilling, or unable to make decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: __________________________
____________________________ Cell Phone: ___________________________
I AUTHORIZE my agent to make health care decisions for me when I cannot make or communicate
my own health care decisions. I want my agent to make all such decisions for me except any
decisions that I have expressly stated in this form that I do not authorize him/her to make. My agent
should explain to me any choices he or she made if I am able to understand. I further authorize my
agent to have access to my “personal protected health care information and medical records”. This
appointment is effective unless it is revoked by me or by a court order

Health care decisions that I expressly DO NOT AUTHORIZE if I am unable to make decisions
for myself: (Explain or write in "None")
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
My specific wishes regarding autopsy (additional information on page 1):
*Please note that if not required by law a voluntary autopsy may cost money. Initial your choice

_____: Upon my death I DO NOT consent to a voluntary autopsy

_____: Upon my death I DO consent to a voluntary autopsy

_____: My agent may give or refuse consent for an autopsy

Life Care Planning: Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 03/2020 Mark Brnovich 2 of 5
My specific wishes regarding organ donation (additional information on page 1):
If you do not initial this section your agent may make these decisions for you. Initial your choice

_____: I DO NOT WANT to make an organ or tissue donation, and I DO NOT want this donation
authorized on my behalf by my agent or my family

_____: I have already signed a written agreement or donor card regarding donation with the following
individual or institution: ________________________________________________________
_____: I DO WANT to make an organ or tissue donation when I die. Here are my directions:
1. What organs/tissues I choose to donate (initial below):
a. _____: Whole body
b. _____: Any needed parts or organs
c. _____: These parts or organs only:
i. _____________________________________________________________________________
2. I am donating organs/tissue for (initial below):
a. _____: Any legally authorized purpose
b. _____: Transplant or therapeutic purposes only
c. _____: Research only
d. _____: Other: _______________________________________________________
3. The organization or person I want my organs/tissue to go to are (initial below):
a. _____: _____________________________________________________________
b. _____: Any that my agent chooses
My specific wishes regarding funeral and burial disposition (additional information on page 1):
_____: Upon my death, I direct my body to be buried. (Instead of cremated)
_____: Upon my death, I direct my body to be buried in: ____________________________________
_____: 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 ___________________
__________________________________________________________________________
_____: My agent will make all funeral and burial decisions

Life Care Planning: Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 03/2020 Mark Brnovich 3 of 5

The Arizona Attorney General’s Office wants to make sure that all Arizonans have access to these free legal documents, all of which are in line with Arizona Law. The Attorney General’s Office is just one of several places to get forms and information on life care planning. The Attorney General's

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Frequently Asked Questions

Where can i find life care planning forms in arizona?

(The Life Care Planning forms available on this website are courtesy of the Office of the Attorney General of Arizona, Mark Brnovich .) The Advance Directive Registry at the Arizona Secretary of State's Office is a free registry to electronically store and access your medical directives.

How do i request a life care plan lcp?

Complete a Life Care Planning request form or call (602) 542-2123 or (800) 352-8431 to have them mailed to you. Paquete LCP completo - Próximamente estará disponible una versión actualizada de este paquete en español

Do i need an attorney to complete the forms in arizona?

Each form has different requirements for completion under Arizona law, so be sure you follow all the individual instructions on each form. You do not need an attorney to help you complete the forms. The forms are available at no cost to you by: Downloading the complete packet or individual forms below.