Illinois Statutory Short Form Power Of Attorney For Property (Page 5 of 7) in pdf

EXHIBIT A

THIS EXHIBIT, WHICH IS ATTACHED TO ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR PROPERTY (HEREINAFTER REFERRED

TO AS "POWER"), IS HEREBY INCORPORATED THEREIN AND MADE A PART THEREOF BY REFERENCE.

I grant my agent the power to transfer assets to an “OBRA 93 Pay Back Trust” established pursuant to 89 Ill. Admin Code Ch. 1, Sect. 120.347(d)(1);

89 Ill. Admin. Code, Ch. 1, Sect. 120.314; Subparagraph (A) of Section 1917(d)(4) of the Social Security Act; Social Security Administration POM SI 01 120.203

(specifically including the “Procedure” set forth at SI 01120.203D.1); 760 ILCS 5/15.1; 42 U.S.C. 1382b; and 42 U.S.C. 1396p, amended August 10, 1993, by the

Revenue Reconciliation Act of 1993, specifically subsections (d)(4)(A) and (C); in order to impoverish myself, with the express intention to qualify for Medicaid or

Medicaid Waiver Programs, and/or other government benefits or programs that might be, or in the future may be available due to the fact that I am disabled as

defined by the Social Security Administration.

I grant my agent the full power to represent me in all matters related to my application for, and/or maintenance of SSI, SSDI, Medicaid, Medicare, as

well as other government benefits.

I grant my agent the full power to represent me in all matters related directly or indirectly to my living arrangements, such as Skilled Nursing Facility,

Intermediate Care Facility, Supported Living Arrangement, Community Integrated Living Arrangement, Section 8 Housing, private housing, or other.

I grant my agent the full power to represent me in all matters related directly or indirectly to my school and/or educational matters, employment

matters, vocational training matters, transition planning matters, supported employment matters, regular work or sheltered employment matters, Developmental

Training Program and related matters.

I grant my agent the power to exercise my right to disclaim an interest or interests in property in accordance with Section 2.7 of the Illinois Probate

Act, to exercise my right of renunciation of my spouse's, if any, will in accordance with Section 2.8 of the Illinois Probate Act, to act as my attorney in fact with

regard to the Internal Revenue Service and the Illinois Department of Revenue for the tax years 1970 through 2090 and authorize their execution of I.R.S. Form

2848 and Illinois Department of Revenue Form IL 2848 or successor forms, authorizing a CPA and/or attorney to represent me in any such income tax matter(s).

I further grant to my agent the power to make gifts of my property in order to impoverish myself with the express intention to qualify for Medicaid and/or other

government benefits available to provide for my medical care and support.

11.

Reproductions of the executed original Power of Attorney, certified as a true, exact and accurate copy of the original Power of Attorney by my attorney in

fact, or my agent in possession of the original, shall be deemed original counterparts of this Power of Attorney.

12.

HIPAA Release Authority. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually

identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and

Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45CFR 160-164. I authorize:

any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider, any insurance

•

company and the Medical Information Bureau Inc. or other health care clearinghouse that has provided treatment or services to me or that has paid for or is

seeking payment from me for such services

to give, disclose and release to my agent, without restriction,

•

all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include

•

all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse.

The authority given 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 authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in

writing and deliver it to my health care provider.

______________________________________________

Signature of principal

State of

)

County of

) SS.

The undersigned, a notary public in and for the above County and State, certifies that

known to me to be the same person whose name is subscribed as principal to the foregoing power of attorney, appeared before me in person and acknowledged

signing and delivering the instrument as the free and voluntary act of the principal, for the uses and purposes therein set forth, (and certified to the correctness of

the signature(s) of the agent(s)).

Dated

Notary Public

My commission expires:

The undersigned witness certifies that _____________________________________________, known to me to be the same person whose name is

subscribed as principal to the foregoing power of attorney, appeared before me and the notary public and acknowledged signing and delivering the instrument as

the free and voluntary act of the principal, for the uses and purposes therein set forth. I believe him or her to be of sound mind and memory.

__________________________________________________

Residing at __________________________________________________

(witness)

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