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HEALTH CARE PROXY
. DESIGNATION OF HEALTH CARE PROXY. If I should become permanently unconscious, incompetent, or otherwise mentally or physically incapable of communication, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to follow the instructions of my Agent whom I appoint as my Health Care Proxy ("Agent") to decide whether life-sustaining treatment
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. GENERAL PROVISIONS.
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST DATE AND SIGN THIS DOCUMENT)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on ______ day of ____________________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
voluntarily signed this writing in my presence.
We, the undersigned, state that we are both at least 18 years of age.
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
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It's very easy to grant or receive the support you might need using a free Arkansas Medical Power of Attorney template from Rocket Lawyer:
This solution is often much more affordable and convenient than meeting and hiring the average provider. If necessary, you can fill out this Medical PoA on behalf of an elderly parent, a spouse, or another family member, and then help them sign after you've drafted it. Please keep in mind that for a PoA form to be valid, the principal must be mentally competent when they sign. If the principal is already unable to make their own decisions, a court-appointed conservatorship might be required. When managing such a scenario, it is important to speak with an attorney .
Anyone who is over 18 ought to have a Medical Power of Attorney. Though it can be tough to acknowledge, a day will likely come when you are not able to make your own healthcare decisions. Here are a few typical circumstances in which a PoA may be helpful:
Regardless of whether your Arkansas Medical Power of Attorney is being generated as part of a long-term plan or produced as a result of an unexpected emergency, notarization and/or witnesses will often help to protect your document if a third party disputes its authenticity.
At times, in the process of researching the topics of elder care and/or estate planning, you or a loved one may see the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together. In actuality, they're the same. That said, you should keep in mind that it's entirely possible to grant agency over matters that aren't related to medical care. In that case, "proxy" is not commonly used.
Arkansas Medical PoA forms are generally simple; however, you could have legal questions. Finding a lawyer to look over your Medical Power of Attorney could take longer than you expect if you attempt to do it on your own. An easier approach would be through attorney services at Rocket Lawyer. Rocket Lawyer members have the ability to ask for guidance from an experienced lawyer or send additional questions. As always, you can be confident that Rocket Lawyer is by your side.
The fees associated with finding and hiring your average lawyer to write a Medical Power of Attorney might total anywhere from $200 to $500, based on your location. Rocket Lawyer is not a run-of-the-mill Power of Attorney template website. With us, anyone under a Rocket Lawyer Premium membership can take advantage of up to 40% in savings when hiring an attorney from our Rocket Lawyer attorney network.
Each Power of Attorney has a list of tips on what to do next. You are encouraged to engage with the document in any of these ways: making edits, downloading it in PDF format or as a Word file, and signing it. Finally, ensure that your agent(s) and care providers get a copy of your final document.
The specific rules and restrictions vary by state; however, in Arkansas, your Power of Attorney must be acknowledged by a notary public or signed by two witnesses. At least one witness to this PoA must be someone who is not a relative, spouse, adoptee, heir, or any other beneficiary. Finally, as a general standard, your witness(es) will need to not be under the age of 18, and no witness should also be your PoA agent.
See Arkansas Medical/Healthcare Power of Attorney law: Title 20, Subtitle 2, Ch. 6, Subchapter 1
