Durable Power Of Attorney Form - State Of Washington Page 2
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5authorized, cross out all of paragraph D.)
No gift may be made under this power of attorney, except to a spouse or
registered domestic partner if authorized under paragraph 1(C), unless authorized
by this paragraph.
2. EFFECTIVE DATE, REVOCATION AND DISPOSITION OF REMAINS
A. This power of attorney shall become effective (initial the choice that
applies):
1. ________ immediately
2. ________only when my agent, who may consult with any medical and/or legal
professionals as he/she deems necessary or appropriate, certifies in writing that I lack the
mental capacity to make important decisions independently. (This certification may be
made using the box at the end of this document, or may be made in a separate
writing.)
For purposes of obtaining information from a physician to determine if I am
incapacitated, my agent shall be entitled to obtain and use any of my medical records or
other individually identifiable health information to the same extent as I would myself.
This is intended as a full release of all information governed by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
3. ________ only when my incompetence or disability has been established by a written,
dated statement signed by a qualified physician who has regularly attended me for the last
two most recent years prior to disability or incompetence, or, in the absence of such a
physician, by the unanimous agreement of two qualified physicians who have examined
me and reviewed my medical history. (This certification may be made using the box at
the end of this document, or may be made in a separate writing.).
For purposes of obtaining a certification of incompetency or disability from a
physician, my agent shall be entitled to obtain and use any of my medical records or other
individually identifiable health information to the same extent as I would myself. This is
intended as a full release of all information governed by the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
B. This power of attorney shall remain in effect until revoked or until my death.
C. After my death, my agent shall have the authority to act as my
representative for purposes of controlling the disposition of my remains, as
authorized under RCW 68.50.16, if I have not otherwise made lawful provision
for their disposition.
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