Medical Power Of Attorney And Hipaa Release Authorization (Page 2 of 4) in pdf

Medical Power Of Attorney And Hipaa Release Authorization Page 2

medical records regarding any past, present or future medical or mental health condition, including

all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases,

mental illness, and drug or alcohol abuse. Additionally, my agent shall have the ability to ask

questions and discuss my protected medical information with the person or entity who has possession

of the protected medical information even if I am fully competent to ask questions and discuss this

matter at the time. It is my intention to give a full authorization to any protected medical information

to my agent. Such information may also be released to any person designated as a primary or

successor agent or attorney-in-fact in a durable power of attorney which I have executed, whether

or not such person is presently serving as such, and to any person presently serving as trustee or

named as a successor trustee in any revocable or irrevocable trust created by me as trustor.

In determining whether I am incapacitated, all individually identifiable health information

and medical records shall be released to the person who is nominated as my agent hereunder,

including any written opinion relating to my incapacity that the person nominated as my agent may

have requested. This release authority applies to any information governed by HIPAA and applies

even if that person has not yet begun serving as my agent.

This authority given to my agent shall supersede any prior agreement that I may have made

with my health-care providers to restrict access to or disclosure of my individually identifiable health

information. The individually identifiable health information and other medical records given,

disclosed, or released to my agent may be subject to redisclosure by my agent and may no longer be

protected by HIPAA. The authority given to my agent herein has no expiration date and shall expire

only in the event that I revoke this Medical Power of Attorney in writing and deliver it to my health-

care provider. There are no exceptions to my right to revoke this Medical Power of Attorney.

ORIGINAL

The original of this document is kept at:

123 Apple Way, Houston, Texas 77777

COPIES

The following individuals or institutions have copies of the signed originals:

Name:

JANE DOE

Address:

123 Apple Way, Houston, Texas 77777

Name:

JAMES DOE

Medical Power Of Attorney And Hipaa Release Authorization Page 2