Common use of PLEASE READ THIS DOCUMENT CAREFULLY Clause in Contracts

PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx Processing time: up to three weeks. REQUIRED REGISTRANT INFORMATION Last Name: First Name: Middle Name: Address: Date of Birth: MM/DD/YYYY City: State: Zip: Phone: I choose to opt out of SMS text Email: I choose to opt out of email Mailing address if different from above: City: State: Zip: Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once your account has been activated and your documents have been uploaded to the AzHDR, Health Current will not retain paper copies of your advance directives. Additionally, any documents received by Health Current that are not advance directives or attachments thereto will not be accepted and will be shredded and securely destroyed. Arizona Healthcare Directives Registry Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx | xxxxx.xxx Arizona Advance Directives Registration Agreement Terms & Conditions

PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx documents@azhdr,org Processing time: up to three weeks. REQUIRED REGISTRANT INFORMATION Last Name: First Name: Middle Name: Address: Date of Birth: MM/DD/YYYY City: State: Zip: Phone: I choose to opt out of SMS text Email: I choose to opt out of email Mailing address if different from above: City: State: Zip: Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once your account has been activated and your documents have been uploaded to the AzHDR, Health Current will not retain paper copies of your advance directives. Additionally, any documents received by Health Current that are not advance directives or attachments thereto will not be accepted and will be shredded and securely destroyed. Arizona Healthcare Directives Registry Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx | xxxxx.xxx Arizona Advance Directives Registration Agreement Terms & Conditions

PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx Processing time: up to three weeks. REQUIRED REGISTRANT INFORMATION Last Name: First Name: Middle Name: Address: Date of Birth: MM/DD/YYYY City: State: Zip: Phone: I choose to opt out of SMS text Email: I choose to opt out of email Mailing address if different from above: City: State: Zip: Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Please note: All documents submitted to Health Current must be copies. Please do not submit originals. Once your account has been activated and your documents have been uploaded to the AzHDR, Health Current will not retain paper copies of your advance directives. Additionally, any documents received by Health Current that are not advance directives or attachments thereto will not be accepted and will be shredded and securely destroyed. Arizona Healthcare Directives Registry Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx xxxxx@xxxxxxxxxx.xxx | xxxxx.xxx Arizona Advance Directives Registration Agreement Terms & Conditions