Skip navigation

Home POLST Additional Forms

Advance Care Planning Forms

Planning Today for Medical Care Tomorrow

So, you are ready to get started. What form do you need to fill out? Arizona does not specify which forms you must use. Here are some options:

Arizona Short Forms: Living Will and Healthcare Power of Attorney - English / Spanish

Prepare for Your Care; a large print form - English / Spanish

Prehospital Medical Care Directive

POLST form for your provider to complete

Attorney General’s Forms


 

Documenting Your Wishes for Future Medical Treatment

Having Thoughtful Life Conversations jump-starts your efforts to ensure you receive only the medical treatments you approve of if you are unable to speak for yourself. Putting your thoughts into writing legally through advance directives, also known as healthcare directives, and other forms ensures medical professionals and family members are able to carry out your wishes.

These are the forms Thoughtful Life Conversations (TLC) suggests because they are simple and meet legal requirements.

TLC recommends that all competent adults over the age of 18 have a Living Will and a Health Care Power of Attorney.

Q: Why should I complete an advance directive?

A: Advance directives are legal documents that help you communicate future healthcare treatment decisions and appoint someone to speak for you if you are not able to speak for yourself

 

Types of Advance Care Planning Forms:

1. Living Will - Fill out to plan for your future care

A Living Will is a written statement that expresses your wishes about medical care if you are ever in a terminal condition, a persistent vegetative state or an irreversible coma. You should talk to your doctor about what these terms mean (Office of the Attorney General of Arizona, Life Care Planning Packet).

The Living Will must be signed and witnessed or notarized. It is a standalone document that may also have other advance care planning documents attached to it.


What to do once you’ve filled out your Living Will

For details on registering your Living Will with the Arizona Secretary of State’s Advance Directive Registry, click here. It is recommended you give a copy of this to the person you have appointed as your healthcare power of attorney, your loved ones and healthcare providers.

 

2. Healthcare Power of Attorney (Second page in the document)- Fill out if you want to designate someone to speak for you

The Durable Healthcare Power of Attorney is a document that lets you choose another person, called an "agent," to make healthcare decisions if you can no longer make those decisions for yourself. Unless the document includes specific limits, the agent will have broad authority to make any healthcare decision you could normally make for yourself. This could include a decision about whether or not to continue tube feeding. (Office of the Attorney General of Arizona, Life Care Planning Packet, Frequently Asked Questions)

The Health Care Power of Attorney must be signed or notarized, and attached to your Living Will.


What to do once you’ve filled out your Healthcare (Medical) Power of Attorney

For details on registering your Health Care (Medical) Power of Attorney with the Arizona Secretary of State’s Advance Directive Registry, click here. It is recommended you give a copy of this to the person you have appointed as your healthcare power of attorney, your loved ones and healthcare providers.

 

3. Durable Mental Healthcare Power of Attorney (second page in the document) – Fill this out if you want to designate someone to speak for you about your mental healthcare decisions

The Durable Mental Healthcare Power of Attorney is a document that lets you choose another person, called an "agent," to make mental healthcare decisions if you can no longer make those decisions for yourself.


What to do once you’ve filled out your Durable Mental Healthcare Power of Attorney

For details on registering your Durable Mental Healthcare Power of Attorney with the Arizona Secretary of State’s Advance Directive Registry, click here. It is recommended you give a copy of this to the person you have appointed as your healthcare power of attorney, your loved ones and healthcare providers.

 

4. Prehospital Medical Care Directive or Do Not Resuscitate (The Orange Form) - Fill out if you do not want to be resuscitated by EMS

The Prehospital Medical Care Directive, or Do Not Resuscitate (DNR) form, informs emergency personnel outside of a hospital setting that if you stop breathing or your heart stops beating, they are not to start cardiopulmonary resuscitation (CPR), nor use equipment, drugs or devices to restart your heart or breathing.

Print this form in color on letter-size (8.5” x 11”) paper and display it in plain sight in your home. You may also print the form in color on wallet-size paper. The form must be signed by you (the patient), a licensed healthcare provider and a witness.

2 ways to request a DNR form:

  1. Click here to download the DNR form (print on orange paper)

  2. Call 602- 542-2123 or 800-352-8431 and leave a message

Watch Maricopa County’s Do No Resuscitate Informational Video


5. POLST - Fill out with your healthcare provider if you are seriously ill

The POLST form helps seriously ill or frail patients get the medical treatments they want and avoid medical treatments they do not want. POLST forms are completed by a patient’s healthcare provider (physician, PA or NP) after discussing what is important to them, their diagnosis, what is likely to happen in the future and what their treatment options are. While an advance directive is for anyone that is 18 or older for future care a POLST form is only for those who are seriously ill or frail for current care. 

The POLST form is a portable medical order that follows the patient and helps healthcare providers understand the goals of care whenever or wherever the patient has a medical emergency and can’t speak for him or herself. Meant for individuals with a serious illness or frailty whose healthcare providers would not be surprised if they died within a year or so, the POLST form must be signed by both the patient and healthcare provider.


What to do once you’ve completed your POLST form with your healthcare provider

It's recommended you update your Living Will at the same time you complete your POLST form and attach the documents to each other. All documents should be sent to the Arizona Healthcare Directive Registry, shared with all healthcare providers and loved ones. A POLST form is always voluntary and can be updated as needed.

Click here for more information on POLST.