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Fillable Medical Power of Attorney Form for Arkansas

The Arkansas Medical Power of Attorney form allows individuals to designate a trusted person to make healthcare decisions on their behalf if they become unable to do so. This important document ensures that your medical preferences are respected and followed during critical times. To take control of your healthcare decisions, consider filling out the form by clicking the button below.

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The Arkansas Medical Power of Attorney form serves as a crucial legal instrument that empowers individuals to make healthcare decisions on behalf of another person, particularly when that individual is unable to communicate their wishes due to illness or incapacitation. This form allows a designated agent, often a trusted family member or close friend, to step into the role of decision-maker, ensuring that the patient’s medical preferences are honored. Key aspects of the form include the specification of the agent's authority, which can encompass a wide range of healthcare decisions, from routine medical treatments to end-of-life care. It also allows for the inclusion of specific instructions regarding the types of medical interventions the patient would or would not want, thus providing clarity and guidance during challenging times. Additionally, the form must be signed in accordance with state regulations to be valid, which typically involves the presence of witnesses or a notary public. Understanding these elements is vital for anyone considering the use of a Medical Power of Attorney in Arkansas, as it not only facilitates informed decision-making but also fosters peace of mind for both the patient and their loved ones.

Form Sample

This Arkansas Medical Power of Attorney is granted under the authority of the Arkansas Health Care Decisions Act. It empowers an individual of your choosing to make health care decisions on your behalf if you become unable to decide for yourself.

Principal's Information:

Full Name: _______________________________________________
Address: __________________________________________________
City, State, Zip: ___________________________________________
Primary Phone: _____________________________________________
Email Address: _____________________________________________

Agent’s Information:

Full Name: _______________________________________________
Address: __________________________________________________
City, State, Zip: ___________________________________________
Primary Phone: _____________________________________________
Email Address: _____________________________________________

Alternate Agent’s Information (if primary agent is unable to serve):

Full Name: _______________________________________________
Address: __________________________________________________
City, State, Zip: ___________________________________________
Primary Phone: _____________________________________________
Email Address: _____________________________________________

The Principal grants to the Agent full power and authority to make health care decisions on the Principal's behalf, including but not limited to:

Consent, refuse, or withdraw consent to any type of health care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
Make decisions about the use of artificial nutrition and hydration and all other forms of health care, including palliative care and hospice.
Have access to the Principal’s medical records and information to the extent permitted by law, to make informed decisions about the Principal's care.
Choose or discharge health care providers and institutions.
Approve or disapprove diagnostic tests, surgical procedures, programs of medication, and directions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care.

This Medical Power of Attorney becomes effective immediately upon the incapacitation of the Principal and will continue in effect until the Principal is no longer incapacitated or until it is revoked.

Signature of Principal: _______________________________ Date: _______________

Signature of Agent: _________________________________ Date: _______________

Witness Declaration:

This document was signed in my presence. The Principal appeared to be of sound mind and free of duress, fraud, or undue influence. I am not the Principal’s health care provider, an employee of the health care provider, the named agent, the spouse of the agent, nor related by blood or marriage to the Principal.

Witness 1: _________________________________________ Date: _______________

Witness 2: _________________________________________ Date: _______________

State of Arkansas
County of ___________________

Subscribed and sworn before me this ______ day of ___________, 20__.

Notary Public: _____________________________________

My commission expires: _____________________________

⇓ Medical Power of Attorney PDF Form

Document Overview

Fact Name	Details
Definition	The Arkansas Medical Power of Attorney allows an individual to designate someone to make healthcare decisions on their behalf if they become incapacitated.
Governing Law	This form is governed by the Arkansas Code Annotated, specifically Title 20, Chapter 13.
Eligibility	Any adult resident of Arkansas can create a Medical Power of Attorney.
Agent Requirements	The appointed agent must be at least 18 years old and cannot be the individual’s healthcare provider or an employee of the healthcare provider.
Execution Requirements	The form must be signed by the principal in the presence of two witnesses or notarized to be valid.
Revocation	A Medical Power of Attorney can be revoked at any time by the principal, as long as they are competent to do so.
Durability	The authority granted remains effective even if the principal becomes incapacitated, unless revoked.

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