Fillable Official Durable Power Of Attorney Form (Page 6 of 9) in pdf

Official Durable Power Of Attorney Form Page 6

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copy via: physical copy, email, or fax that I, the Principal, will indemnify and

hold harmless any and all claims that may be put forth in reference to this

Durable Power of Attorney Form.

X. COMPENSATION – The Attorney-in-Fact agrees not to be compensated for

acting in the presence of the Principal. The Attorney-in-Fact may be, but not

entitled to, reimbursement for all: food, travel, and lodging expenses for

acting in the presence of the Principal.

XI. DISCLOSURE - I intend for my attorney-in-fact under this Power of Attorney

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 45 CFR 160-164

XII. PRINCIPAL’S SIGNATURE - I,

, the Principal,

Printed Name of Principal

sign my name to this power of attorney this

day of

Day

and, being first duly sworn, do declare to the

Month

undersigned authority that I sign and execute this instrument as my power of

attorney and that I sign it willingly, or willingly direct another to sign for me,

that I execute it as my free and voluntary act for the purposes expressed in the

power of attorney and that I am eighteen years of age or older, of sound mind

and under no constraint or undue influence.

Signature of Principal

XIII. ATTORNEY-IN-FACT’S SIGNATURE- I,

Name of Attorney-in-Fact

have read the attached power of attorney and am the person identified as the

attorney-in-fact for the principal. I hereby acknowledge and accept my

appointment as Attorney-in-Fact and that when I act as agent I shall exercise

the powers for the benefit of the principal; I shall keep the assets of the

principal separate from my assets; I shall exercise reasonable caution and

prudence; and I shall keep a full and accurate record of all actions, receipts

and disbursements on behalf of the principal.

Signature of Attorney-in-Fact

Date

Official Durable Power Of Attorney Form Page 6

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