Medical Power Of Attorney And Hipaa Release Authorization (Page 3 of 4) in pdf

Medical Power Of Attorney And Hipaa Release Authorization Page 3

Address:

321 Orange Lane, Houston, Texas 77777

DURATION

I understand that this power of attorney exists indefinitely from the date I execute this

document unless I establish a shorter time or revoke the power of attorney. However, if I do

establish a shorter time for the existence of this power of attorney and if I am unable to make health

care decisions for myself when this power of attorney does expire, the authority I have granted my

agent shall, nevertheless, continue to exist until the time I become able to make health care decisions

for myself.

PRIOR DESIGNATIONS REVOKED

I revoke any prior durable power of attorney for health care and any prior medical power of

attorney.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT

I have been provided with a disclosure statement explaining the effect of this document. I

have read and understand the information contained in the disclosure statement.

I sign my name to this medical power of attorney on _________________________, 2011,

at Johnson County, Texas.

JOHN DOE, Principal

STATEMENT OF FIRST WITNESS

I am not the person appointed as agent by this document. I am not related to the principal

by blood or marriage. I would not be entitled to any portion of the principal's estate on the principal's

death. I am not the attending physician of the principal or an employee of the attending physician.

I have no claim against any portion of the principal's estate on the principal's death. Furthermore,

if I am an employee of a health care facility in which the principal is a patient, I am not involved in

providing direct patient care to the principal and am not an officer, director, partner, or business

office employee of the health care facility or of any parent organization of the health care facility.

Signature:

Print Name:

Medical Power Of Attorney And Hipaa Release Authorization Page 3