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DOCUMENT:
HEADER:
Title: "Notice Regarding Healthcare Proxy Compliance"
Date: "4/24/2025"
Intro: "This notice is provided pursuant to the duty to comply with Arizona law regarding
healthcare directives and related obligations."
STATUTORY_AUTHORITY:
Citation: "ARS Title 36, Chapter 32"
Description: "Governing the rights of patients and the authority of healthcare agents in
advance directives and living wills."
PATIENT_INFORMATION:
Patient Name: "Kaliska-rae Hogan"
Proxy Appointment: "April Walters is designated as the Healthcare Agent to make all
healthcare decisions on behalf of Kaliska-rae Hogan."
HIPAA_RELEASE:
Reference: "ARS §36-3236"
Text: "I hereby authorize the responsible healthcare providers and their representatives to
disclose protected health information regarding my condition, treatment, and medical history to
my designated healthcare agent, April Walters, as necessary to facilitate healthcare decision-
making on my behalf. This authorization is valid for all disclosures related to health care
decisions and shall remain in effect until my recovery, revocation by me, or as required by law."
CASE_LAW_REFERENCES:
1. Henry v. Flagstaff Medical Center, Inc. – Establishes the test for apparent agency in the
healthcare context.
2. Rasmussen by Mitchell v. Fleming – Provides a legal framework for the right to refuse
medical treatment and outlines boundaries of healthcare agent authority.
3. Snell & Wilmer L.L.P. v. Fegen – Clarifies fiduciary duties and responsibilities relevant
to healthcare agents.
4. Wilmot v. Wilmot – Emphasizes the duty of fairness and the fiduciary responsibilities
owed by decision-makers.
5. Escareno Ex Rel. Estate of Escareno v. Kindred Nursing Centers West, L.L.C. –
Discusses agency principles and the authority of a representative under healthcare agreements.
ACKNOWLEDGMENT_REQUEST:
Request List:
• "Acknowledge the validity of the healthcare proxy and the authority granted to April
Walters."
• "Attach a copy of this notice to the appropriate medical records."
• "Provide written confirmation of receipt and acknowledgment of this notice."
SIGNATURE_BLOCK:
Agent:
Name: "April Walters"
Signature Line: "___"
Date: "4/24/2025"
Witness/Notary:
Instruction: "Witness/Notary acknowledgment required as per Arizona law."
Notary:
State: "Arizona"
County: ""
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Signature Line: "_______________________"
Commission Expiry: "________________"
DELIVERY_INSTRUCTIONS:
Return Address:
Name: "April Walters"
Address: "13810 N. 47th Avenue, Glendale, AZ 85306"
Phone: "480-806-8469"
Email: "
[email protected]"
Instructions: "Deliver a written acknowledgment of receipt of this notice to the return
address provided or via secure electronic communication according to established procedures.
Ensure that a copy of this notice is attached to the appropriate medical records."
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