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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 85007This 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 OthersLife Care Planning: Information Office of the Attorney General of Arizona,Updated 03/2020 Mark Brnovich 2 of 6 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,Updated 03/2020 Mark Brnovich 3 of 6 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,Updated 03/2020 Mark Brnovich 4 of 6 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,Updated 03/2020 Mark Brnovich 5 of 6 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 AGREEMENTI am providing this personal information, along with a copy of my advance directive, with theunderstanding 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 advancedirective, and was duly executed, witnessed and acknowledged in accordance with the laws of theState of Arizona
I understand this authorization is voluntary. This authorization to store my advance directive in theArizona Health Care Directives Registry will remain in force until revoked by me. I understand that Imay revoke this authorization at any time by giving written notice of my revocation to the ContactOffice listed below. I understand that revocation of this authorization will NOT affect any action youtook in reliance on this authorization before you received my written notice of revocation
Contact Office: Office of the Arizona Secretary of StateTelephone: 602-542-6187 E-mail: [email protected]Address: 1700 W. Washington Street, 7th Floor, Phoenix, AZ, 85007Your registration form will be processed within three (3) weeks. You will receive further information inthe mail. In order to complete the registration of your health care directive(s) you are required to replyto the letter that you will receive
For further assistance please contact the Arizona Secretary of State at (602) 542-6187 or visit usonline 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 signedLife 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
(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.
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
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.