POWER OF ATTORNEY FOR HEALTH CARE
OF A MINOR DEPENDENT
1.
Appointment of Agent. I, _________________________, as parent and legal
guardian of __________________________ (D.O.B. ____________), a minor, hereby
appoint the following individual as my agent to make health care decisions or mental health
care decisions for ____________________________, my child (my “agent”):
NAME:
______________________________________
ADDRESS: ______________________________________
PHONE:
_____________ (h) ; ________________ (w); _______________ (c)
If the above-named individual cannot be contacted in time or for any other
reason is unavailable, unable or unwilling to act as my agent, or is unwilling to comply with
any of the provisions of this Advance Directive, then I appoint the following individual as
my agent in place of the above-named individual:
NAME:
Building Families for Children
ADDRESS: 7161-A Columbia Gateway Drive, Columbia, MD 21046
PHONE:
(800) 621-8834
2.
Powers of Agent. My agent has full power and authority to make health care
decisions or mental health care decisions for my child and to give necessary consent or
approval for any routine or emergency medical or other professional care, counsel, treatment,
or service for my child, or to withhold or withdraw such treatment, including but not limited
to the power to:
a.
Release of Medical Information. Request, receive, and review any
information, oral or written, regarding my child’s physical or mental health, including, but
not limited to, medical and hospital records, and to consent to the disclosure of this
information; this authority is specifically intended to comply with any and all requirements
of the Health Insurance Portability and Accountability Act of 1996, as amended, 42 USC
1320 d and 45 CFR 160-164 (“HIPAA”), to authorize my agent (personal representative) to
access and disclose my child’s confidential medical information (or individually identifiable
health information and protected health information, as these terms are defined under
HIPAA) as contemplated herein, including, but not limited to health information and medical
records regarding any past, present or future medical or mental health condition, as well all
information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted
diseases, mental illness and drug or alcohol abuse;
b.
Employment of Health Care Providers. Employ and discharge my
child’s health care providers or mental health care providers;
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Created on 6/2/10