Health Care Power Of Attorney Page 4
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12G. Access to my Health Information – Federal Privacy Law (HIPAA) Authorization
1. If, prior to the time the person selected as my agent has power to act under this
document, my doctor wants to discuss with that person my capacity to make my
own health care decisions, I authorize my doctor to disclose protected health
information which relates to that issue.
2. Once my agent has full power to act under this document, my agent may request,
receive, and review any information, oral or written, regarding my physical or
mental health, including, but not limited to, medical and hospital records and other
protected health information, and consent to disclosure of this information.
3. For all purposes related to this document, my agent is my personal representative
under the Health Insurance Portability and Accountability Act (HIPAA). My agent
may sign, as my personal representative, any release forms or other HIPAA‐related
materials.
H. Effectiveness of this Part
(Read both of these statements carefully. Then, initial one only.)
My agent’s power is in effect:
1. Immediately after I sign this document, subject to my right to make any decision
about my health care if I want and am able to.
✎__________
>>OR<<
2. Whenever I am not able to make informed decisions about my health care, either
because the doctor in charge of my care (attending physician) decides that I have
lost this ability temporarily, or my attending physician and a consulting doctor
agree that I have lost this ability permanently.
✎__________
If the only thing you want to do is select a health care agent,
skip Part II. Go to Part III to sign and have the advance
directive witnessed. If you also want to write your treatment
preferences, go to Part II. Also consider becoming an organ
donor, using the separate form for that.
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