Durable Power Of Attorney Form - State Of Missouri (Page 5 of 6) in pdf

subjects such as sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS),

AIDS-related complex (ARC) and human immunodeficiency virus (HIV), behavioral or mental

health services, and treatment for alcohol or drug abuse or addiction. I understand that I may

have access to or receive an accounting of the information to be used or disclosed as provided in

45 C.F.R. Sec. 164.524 et seq. I further understand that authorizing the disclosure of this health

information is voluntary and that I can refuse to sign this authorization. I further understand that

any disclosure of this information carries with it the potential for an unauthorized further

disclosure of this information by third parties and that such further disclosure may not be

protected under HIPAA. In order to induce the disclosing party to disclose the aforesaid private

and/or protected confidential information, I forever release and hold harmless said disclosing

party who relies upon this instrument from any liability under confidentiality rules arising under

HIPAA as a consequence of said disclosure. I authorize my attorney-in-fact to execute any and

all releases or other documents that may be necessary in order to obtain disclosure of my patient

records and other medical information subject to and protected by HIPAA.

Subject to limitations in this document, my agent and attorney-in-fact shall have

all the power and authority necessary to do all the following:

(a) authorize an autopsy;

(b) make a disposition of a part or parts of my body; and

It is my desire and request that no guardian or conservator of my person or

property be appointed in the event of my disability or incapacity. If, however, a guardian or

conservator of my person or property is to be appointed for me, I hereby nominate and appoint

my attorney-in-fact hereunder to serve as guardian and conservator without bond.

To induce any third party to act hereunder, I hereby agree that any third party

receiving a duly executed copy or facsimile of this power of attorney may act hereunder, and that

revocation or termination hereof shall be ineffective as to such third party unless and until actual

notice or knowledge of such revocation or termination shall have been received by such third

party. I, for myself and my heirs, executors, legal representatives and assigns, hereby agree to

indemnify and hold harmless any such third party from and against any and all claims that may

arise against such third party by reason of such third party having relied upon the provisions of

this power of attorney.

I hereby revoke any prior general powers of attorney which I have executed (but

not any powers of attorney related to health care).

This power of attorney shall be governed by Missouri law, although I request that

it be honored in any state or other location in which I or my property may be found. If any

provisions hereof shall be unenforceable or invalid, such unenforceability or invalidity shall not

affect the remaining provisions of this power of attorney.

Durable Power Of Attorney Form - State Of Missouri Page 5