General Durable Power Of Attorney Form (Page 5 of 6) in pdf

party knows of revocation or termination. This warranty binds my personal representatives and

successors.

20.

Photographic Copies

My Agent has the right to make copies of this Power, and anyone has the right to rely on

these copies as though they were originals. Anyone who relies on my Agent’s representations,

or on a copy of this Power, will not be liable for permitting my Agent to act under this Power.

21.

Power of Substitution

My Agent shall perform all and every act and thing whatsoever requisite and necessary to

be done, as fully to all intents and purposes as I might or could do if personally present, with full

power of substitution or revocation. I hereby ratify and confirm all that my Agent, or my

Agent’s substitute or substitutes, shall lawfully do or cause to be done by virtue hereof.

22.

Termination

This Power will not be affected by my disability or by any uncertainty as to whether I am

alive, but will be terminated by my written revocation or by my death.

23.

HIPAA Authorization

This instrument is meant to be an unlimited, full and complete authorization for the

release of any and all protected medical information as defined under the Health Insurance

Portability and Accountability Act of 1996 (“HIPAA”), 42 USC 1320d and 45 CFR 160-164, as

amended, and under the rules and regulations thereunder, and covers all protected information.

It is understood that my attorney to whom this authorization is given has my permission to use

and disseminate this information in my attorney’s sole discretion.

I intend for my 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 HIPAA.

I authorize any physician, health care 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

attorney, without restriction, all my individually identifiable health information

and medical records, including 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 attorney 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.

General Durable Power Of Attorney Form Page 5