Power Of Attorney For Health Care Of A Minor Dependent printable pdf download

POWER OF ATTORNEY FOR HEALTH CARE

OF A MINOR DEPENDENT

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

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:

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;

Employment of Health Care Providers. Employ and discharge my

child’s health care providers or mental health care providers;

Created on 6/2/10

Power Of Attorney For Health Care Of A Minor Dependent