Life Care Planning: Mental Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 11/2019 Mark Brnovich
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I choose the following person to act as an alternate to make mental 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: ___________________________
Mental health treatments that I AUTHORIZE if I am unable to make decisions for myself:
Here are the mental health treatments I authorize my agent to make for me if I become incapable of
making my own mental health care decisions due to mental or physical illness, injury, disability, or
incapacity. This appointment is effective unless and until it is revoked by me or by an order of a court.
My agent is authorized to do the following which I have initialed or marked:
_____: To receive medical records and information regarding my mental health treatment and to receive,
review, and consent to disclosure of any of my medical records related to that treatment.
_____: To consent to the administration of any medications recommended by my treating physician.
_____: To admit me to an inpatient or partial psychiatric hospitalization program.
_____: Other: ____________________________________________________________________
Mental health care treatments that I expressly DO NOT AUTHORIZE if I am unable to make
decisions for myself: (Explain or write in "None")
Revocability of this Mental Health Care Power of Attorney: This mental health care power of
attorney or any portion of it may not be revoked and any designated agent may not be disqualified by
me during times that I am found to be unable to give informed consent. However, at all other times I
retain the right to revoke all or any portion of this mental health care power of attorney or to disqualify
any agent designated by me in this document.
HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT
_____ (Initial) I intend for my agent to be treated as I would be with respect to my rights regarding
the use and disclosure of my individually identifiable health information or other medical
records. This release of authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.