Free Arizona Medical Power of Attorney Form

Arizona Medical Power of Attorney Explained

An Arizona medical power of attorney is a document in which you, the principal, name an agent to make health care decisions for you if you cannot make them yourself. The agent is the person you name, and you may also hear this person called a health care agent or proxy. Under section 36-3221 of the Arizona Revised Statutes, if you are an adult you may designate another adult, or more than one adult, to make health care decisions on your behalf.^[1] Under section 36-3223, your agent is entitled to make and communicate health care decisions while you are unable to do so. The appointment is effective until you revoke that authority or it is revoked by court order.^[2]

The FormsPal template pairs the appointment with an advance health care directive, a statement of your end-of-life wishes. Use the sections below to check the Arizona rules and then complete each part of the form.

Arizona Medical Power of Attorney Requirements

Arizona sets rules for how a health care power of attorney is signed and for who may witness it or serve as your agent. They come from section 36-3221 of the Arizona Revised Statutes. The sections below put each rule in plain words, so you can check them before you sign.

Signing and Witness Rules

The principal is the person making the document. The health care power of attorney must be dated and signed or marked by the principal.^[1] It must also contain language that clearly indicates that the principal intends to create a health care power of attorney.^[1]

• It must be notarized or witnessed in writing by at least one adult.^[1]
• The notary or witness affirms being present when the principal dated and signed or marked it, and that the principal appeared to be of sound mind and free from duress at the time.^[1]
• The notary or witness may not be a person designated to make medical decisions on the principal’s behalf, or a person directly involved with the provision of health care to the principal when the document is signed.^[1]

If only one person witnesses the document, that person may not be related to the principal by blood, marriage or adoption. That person also may not be entitled to any part of the principal’s estate by will or by operation of law when the document is signed.^[1] This page does not cover the rule for two or more witnesses, so ask a lawyer or the notary before you choose them.

A statement from your physician is optional. Arizona’s sample health care power of attorney form, in section 36-3224, marks its physician affidavit as optional. It suggests that if you speak with your physician about a treatment choice, you ask your physician to complete the affidavit.^[3]

Agent Restrictions

State law restricts who may serve as agent. A person whose license as a fiduciary has been suspended or revoked under section 14-5651 may not serve as an agent under a power of attorney in any capacity. The exception is a person related to the principal by blood, adoption or marriage.^[1]

Pick someone you trust and talk with them before you name them. That is common practice, not a legal requirement.

Arizona Medical Power of Attorney Form Details

What Does the Arizona Medical Power of Attorney Form Cover?

The FormsPal template is titled Arizona Medical Power of Attorney with Advance Directive and runs seven pages. What each part says comes from the printed text of the form, not from Arizona law. Read all of it before you sign.

• Part I, Power of Attorney for Health Care. You name your agent and an alternate agent here, with phone, email and alternative contact details. Powers A to J list what the agent may do, such as consenting to or refusing medical care, getting access to medical records, arranging pain relief, and arranging funeral and burial or cremation.
• Sections 2 to 7. The printed text says the document takes effect on your incapacity, as certified in writing by your treating physician. It also includes a HIPAA release so your agent can receive your medical records.
• Advance Health Care Directive. This part states your end-of-life wishes. The printed wording asks your providers to withhold or withdraw all treatments other than those needed to keep you comfortable in the situations it lists, and it asks that pain relief be provided at all times.
• General Provisions. These are standard terms for the whole document. One clause replaces earlier health care powers of attorney, living wills and directives to physicians you signed, so check that you want that.
• Signature and notary acknowledgment. The date, signature and printed name sit on page 6. Page 7 is an acknowledgment that a notary public completes.

The advance directive is a serious statement about end-of-life care, so check that it matches what you want. If it does not, talk to a lawyer or your doctor before you sign.

Questions to Settle Before You Sign

A medical power of attorney works best when the people involved know what you want. These questions are common practice, not legal requirements. Talk them through with your agent and your doctor before you fill in the form.

• Does the person you have in mind agree to serve as your agent?
• Does your agent know your wishes about treatment, including the end-of-life wishes in the advance directive?
• Who will hold the original, and who will get copies?
• Do you want to name the same person for money and property decisions? That is a separate document, covered on our Arizona durable power of attorney page and our Arizona general financial power of attorney page.

This page covers health care decisions only, not money or property.

Filling Out the Arizona Medical Power of Attorney Form

The form has 21 fillable fields on pages 1, 6 and 7, and the five steps below follow it in order. Pages 2 to 5 are fixed text with no blanks, so read them before you sign. To start right away, use our fillable power of attorney form, or print the PDF and write your answers by hand.

The screenshots under each step show the FormsPal Arizona medical power of attorney template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. Part I: principal and agent. On page 1, enter your full name and home address as the principal. Next, enter the full name and address of the person you appoint as your agent.

   

2. Agent contact details and alternate agent. Still on page 1, add the agent’s phone number, email and any alternative contact information. In the Alternate Agent paragraph, repeat the agent’s name, then enter the alternate agent’s name and address, followed by the alternate agent’s phone, email and alternative contact.

   

3. Date, signature and printed name. On page 6, after the general provisions, write the date, sign on the signature line and print your name below it.

   

4. Notary acknowledgment: county, date and officer. Page 7 holds the notary acknowledgment. The county, the date, the officer’s name and title, and your name as the person who appeared are completed when you appear before the notary.

   

5. Notary signature and seal. The notary signs on the Signature (Seal) line at the bottom of page 7 and adds the official seal.

   

How Do You Sign and Use a Medical Power of Attorney in Arizona?

Filling in the blanks is only part of the job. The steps below cover what happens around the form, from reading it to handing out copies. Follow the signing rules from the first section of this page.

1. Read the whole form. Go through pages 1 to 5, including the advance directive, and check that it matches your wishes.
2. Check your agent. Confirm that your agent is not barred under agent restrictions.^[1]
3. Choose how to sign. Either have the document notarized, or ask at least one adult to witness it in writing.^[1] Our Arizona notary acknowledgment page explains the notary side.
4. Sign and date on page 6. The notary or witness must be present when you do, and a witness must not be a person designated to make your medical decisions.^[1]
5. Keep and share copies. It is common practice to keep the original somewhere safe and give copies to your agent and your doctor. Some people also add a living will or a do-not-resuscitate order, which are separate documents.

The FormsPal template has no lines for a witness’s name or signature. Page 7 is a notary acknowledgment. If you plan to use a witness instead of a notary, ask a lawyer how to record the witness’s signature before you sign.

Common Mistakes to Avoid

Most problems with a medical power of attorney come from skipped steps, not from the blanks on the form. These are the mistakes to watch for, based on the rules earlier on this page and on the way the template is built.

• Signing with neither a notary nor a witness, when the document must be notarized or witnessed in writing by at least one adult.^[1]
• Using a witness or notary who is the person designated to make medical decisions for you.^[1]
• Using a single witness who is related to you or entitled to part of your estate.^[1]
• Naming an agent whose fiduciary license was suspended or revoked, who may not serve unless related to you.^[1]
• Skipping the advance directive, which states your end-of-life wishes and deserves a careful reading before you sign.
• Looking for witness lines on the template, which has none, so a lawyer or the notary should explain how to record a witness’s signature.
• Leaving the only copy in a drawer, when it is common practice to give copies to your agent and your doctor.

Frequently Asked Questions

Other Arizona Forms
Listed below are other Arizona forms completed by FormsPal users. Consider our simple builder to customize these documents to your needs.

• Arizona Last Will
• Arizona Living Will
• Arizona Small Estate Affidavit
• Arizona Bill of Sale
• Arizona Rental Lease Agreement
• Arizona Eviction Notice

Download a Free Arizona Medical Power of Attorney Form

You can download the Arizona medical power of attorney as a PDF with 21 fillable fields, or build it online and print it. Either way, it must be notarized or witnessed in writing by at least one adult, as Arizona requires.^[1]

Create a free high-quality Arizona Medical Power of Attorney online now!

Create and Print Online Now

General information, not legal or tax advice. Talk to a lawyer or your doctor about your own situation.

Sources

1. Ariz. Rev. Stat. § 36-3221.
2. Ariz. Rev. Stat. § 36-3223. Accessed October 15, 2026.
3. Ariz. Rev. Stat. § 36-3224. Accessed October 15, 2026.

Mara Erlach

Writer & Attorney

Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.