Arizona Mental Health Care Power of Attorney (POA)

📄 Complete the Arizona Mental Health Care Power of Attorney (POA)

❓ What Is This Form For?

This form is different from a general health care power of attorney. It is specifically designed for:

• People who may face serious mental health challenges

• Anyone wanting to plan ahead in case of psychiatric hospitalization or treatment

• Ensuring you receive—or don’t receive—specific kinds of mental health care

It only takes effect if you are determined to be incapable by a licensed psychiatrist, psychologist, or neurologist in Arizona.

📝 Step-by-Step Instructions

Section 1: Your Information (the “Principal”)

What it asks:

• Full legal name

• Date of birth

• Address

• Phone number and email

Helpful Tip: Use accurate and current contact details so providers can identify your document.

Section 2: Appointing Your Mental Health Care Agent

What it asks:

• Name and contact information for your primary agent

• Optionally, name a backup (alternate) agent

Helpful Tip: Choose someone you trust to understand and advocate for your values around mental health care. Talk with them before listing them.

Section 3: What Your Agent Can Do

You can initial or mark which mental health treatments your agent is authorized to approve:

• 📄 Access to your mental health records

• 💊 Consent to psychiatric medications

• 🏥 Admission to inpatient or partial hospitalization programs

• ✍️ Other custom instructions (optional)

Helpful Tip: You don’t need to select all options. Only initial the powers you’re comfortable giving your agent.

Section 4: Treatments You Do NOT Want

What it asks: You can write down specific treatments you do not want your agent to approve—like electroconvulsive therapy, certain medications, or hospitalization.

Helpful Tip: Write “None” if you have no restrictions. Be clear and specific if you want to limit certain types of care.

Section 5: Revoking This Form

You can revoke this form at any time you are considered capable of making decisions. However, during periods of incapacity, the form remains active and cannot be revoked.

Section 6: HIPAA Waiver

You may initial to allow your agent to access your protected mental health records under federal HIPAA laws.

Helpful Tip: Initialing this gives your agent the information they need to help make informed care decisions on your behalf.

✍️ Signature and Verification

You must sign this form in front of either a notary public OR one adult witness (but not both).

Witness/Notary must NOT be:

• Under 18

• Related to you

• Named as your agent

• Entitled to any part of your estate

• Your health care provider

✔️ Final Steps

• Sign in front of a witness or notary Ensure they meet the legal qualifications.

• Make copies Give to your agent, mental health providers, and include in any care or hospital file.

• Keep it accessible Place it in a known location with your other advance directives.

• Register it (optional) Submit a copy to the Arizona Healthcare Directives Registry for digital access by providers.

🛠️ Need Help?

We can walk you through this form, coordinate notarization or witnessing, and help ensure your mental health care choices are honored with compassion and clarity.