Arizona Health Care Directives Registry
ARIZONA SECRETARY OF STATE
1700 W. Washington Street, 7th Floor, Phoenix, AZ 85007-2888
(
6
0
2
) 5
4
2
-6187
(800) 458-5842 (within Arizona)
Website: www.azsos.gov
FOR OFFICE USE ONLY - REV. 01/07/19
REGISTRATION AGREEMENT
P
age 1 of 2
About this agreement:
This agreement shall be used for the registration of a
H
e
a
l
t
h
C
a
r
e Directive in the State of Arizona under the authority of
A.R.S. § 36-3291 - 3297
This form/agreement must be written legibly or computer generated.
For your convenience, this form has been designed to be filled out
and printed online at the website referenced above.
Fees: None
Processing time-frame: three weeks
How to complete this form:
Read this agreement carefully, and fill in all
blank spaces
Attach a copy of your witnessed or notarized Health Care
Directive to this Agreement
DO NOT send your original Health Care Directive Form
Sign and date this Agreement
Return by mail
to:
Arizona Secretary of State
1700 W. Washington Street, 7th Fl., Phoenix, AZ 85007
Return in person: Tucson:
400 W. Co
ngress, Ste. 141
L
ast 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.
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Phoenix: 1700 W. Washington, Ste. 220
