Fillable OFFICE OF THE ARIZONA ATTORNEY GENERAL MARK BRNOVICH (Arizona Attorney General)

Fill Online, Printable, Fillable, Blank OFFICE OF THE ARIZONA ATTORNEY GENERAL MARK BRNOVICH (Arizona Attorney General) Form

Use Fill to complete blank online ARIZONA ATTORNEY GENERAL (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OFFICE OF THE ARIZONA ATTORNEY GENERAL MARK BRNOVICH (Arizona Attorney General)

On average this form takes 7 minutes to complete

The OFFICE OF THE ARIZONA ATTORNEY GENERAL MARK BRNOVICH (Arizona Attorney General) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arizona Attorney General

BROWSE ARIZONA ATTORNEY GENERAL (AZ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Life Care Planning: Mental Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 11/2019 Mark Brnovich
1 of 3
OFFICE OF THE ARIZONA ATTORNEY GENERAL
MARK BRNOVICH
Mental Health Care Power of Attorney
GENERAL INSTRUCTIONS: Use this form if you want to appoint a person, also referred to as your
“agent”, to make future mental health care decisions for you if you become incapable of making those
decisions for yourself.
The decision about whether you are incapable can only be made by a specialist in neurology or an
Arizona licensed psychiatrist or psychologist who will evaluate whether you can give informed
consent. 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 mental health care you do or do not
want.
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 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
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Selection of my mental health care power of attorney and alternate:
I choose the following person to act as my agent to make mental health care decisions for me:
Name: ______________________________ Home Phone: _________________________
Address: ____________________________ Work Phone: _________________________
____________________________ Cell Phone: __________________________
Life Care Planning: Mental Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 11/2019 Mark Brnovich
2 of 3
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.
Life Care Planning: Mental Health Care Office of Arizona Attorney General,
Power of Attorney– Updated 11/2019 Mark Brnovich
3 of 3
MY SIGNATURE VERIFICATION FOR THE MENTAL HEALTH CARE POWER OF ATTORNEY
My Signature (Principal): _____________________________________ Date: _________________
If you are unable to physically sign this document your witness/notary may sign and initial for
you. If applicable, have your witness/notary sign below.
Witness/Notary Verification: The principal of this document directly indicated to me that this Mental
Health Care Power of Attorney expresses their wishes and that they intend to adopt it at this time.
Witness/Notary Signature: __________________________________________________________
Name Printed: ______________________________________________ Date:
_________________
SIGNATURE OF WITNESS (See Page 1 for who CANNOT be a witness)
I was present when this form was signed (or marked). The principal appeared to be of sound mind
and was not forced to sign this form. I affirm that I meet the requirements to be a witness as
indicated on page one of the mental health care power of attorney form.
Witness Signature: __________________________________________ Date:
________________
Name Printed:
____________________________________________________________________
Address:
_________________________________________________________________________
OR
SIGNATURE OF NOTARY (See Page 1 for who CANNOT be a Notary)
Notary Public (NOTE: If a witness signs your form, you SHOULD NOT have a notary sign):
NOTORIAL JURAT: Pertains to all three pages of this State of Arizona Mental Health Care
Power of Attorney dated ____________, 20____________.
STATE OF ARIZONA) ss
COUNTY OF ______________)
________________________________________________
Principal’s Name
Subscribed and sworn (or affirmed) before me this ___________ day of ________, 20 ______
Notary Public Signature: ____________________________________
My Commission Expires: ____________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OFFICE OF THE ARIZONA ATTORNEY GENERAL MARK BRNOVICH (Arizona Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document