Medical Power Of Attorney And Hipaa Release Authorization printable pdf download

Medical Power Of Attorney And Hipaa Release Authorization

MEDICAL POWER OF ATTORNEY

AND HIPAA RELEASE AUTHORIZATION

I, JOHN DOE, designate:

Name:

JANE DOE

123 Apple Way

Address:

Houston, Texas 77777

Phone:

888-888-8888

as my agent (hereinafter referred to as "agent") to make any and all health care decisions for me.

This medical power of attorney takes effect if I become unable to make my own health care decisions

and this fact is certified in writing by my physician.

DESIGNATION OF ALTERNATE AGENT

If JANE DOE is unable or unwilling to make health care decisions for me, I designate the

following person as my agent to make health care decisions for me as authorized by this document:

Name:

JAMES DOE

321 Orange Lane

Address:

Houston, Texas 77777

Phone:

888-888-8888

HIPAA RELEASE AUTHORITY

I intend for my agent to be treated as I would be treated with respect to my rights regarding

the use and disclosure of my individually identifiable health information and other medical records.

This release authority applies to any information governed by the Health Insurance Portability and

Accountability Act of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164. This release authority

is effective immediately.

Accordingly, I hereby authorize any doctor, physician, medical specialist, psychiatrist,

chiropractor, health-care professional, dentist, optometrist, health plan, hospital, hospice, clinic,

laboratory, pharmacy or pharmacy benefit manager, medical facility, pathologist, or other provider

of medical or mental health care, as well as any insurance company and the Medical Information

Bureau Inc. or other health-care clearinghouse that has paid for or is seeking payment from me for

such services, to give, disclose and release to my agent who is named herein and who is currently

serving as such, without restriction, all of my individually identifiable health information and

Medical Power Of Attorney And Hipaa Release Authorization