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<br />involving my federal, state, local or foreign taxes at such address as my attorney-in-fact may ..,,
<br />designate.
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<br />This power of attorney shall take effect upon my becoming physically disa.bled,
<br />mentally incompetent or otherwise incapacitated. Any third party may rely upon the written
<br />declazation of my attorney-in-fact that such contingency has occurred.
<br />It may be necessary for my attorney-in-fact to have access to my medical records
<br />to establish that this power of attorney is in effect. I grant to my attorney-in-fact the authority
<br />and power to serve as my personal representative for a11 purposes of the Health Insurance
<br />Porta.bility and Accountability Act of 1996, the regulations in 45 C.F.R Sea 160 et seq., and any
<br />other applicable federal, sta.te or local laws or regulations (collectively "HIPAA"), including the
<br />authority to request, receive, obtain and review, and be granted full and unlimited access to, and
<br />consent to the disclosure of complete unredacted copies of any and a11 health, medical and
<br />financial information and any information or records referred to in 45 C.F.R. Sec. 164.501 and
<br />regulated by the Standazds for Privacy of Individually Identifiable Health Information found in
<br />65 Fed. Reg. 82462 as protected private records or otherwise covered under HIPAA. I
<br />understand that health and medical records can include information relating to subjects such as
<br />sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), AIDS-related
<br />complex (ARC) and human immunodeficiency virus_�HIV�, b�havi oz, m�,ntal healtli ,�ervices,
<br />and treatment for alcohol or drug abuse or addiction. I understand� t�iat I� may have access to or
<br />receive an accounting of the information to be used or disclosed as provided in 45 C.F.R. Sec.
<br />164.524 et seq. I further understand that authorizing rhe_ d�s.c�s��$ut'e of.xhxs_he,alth �nformation. is
<br />voluntary and that I can refuse to sign this authorization. I fia�t�ex„understan,c�.that auy d,isclosure
<br />of this information cazries with it the potential for an una�t.�o�,zed fiirt�ier disclosure of this
<br />information by third parties and that such further disclosure may not be protected under HIPAA.
<br />In order to induce the disclosing party , to disclose,. the.,, a�q�,e�� „pri�a�e _ ar,u�l�r protected
<br />confidential information, I forever release and hold hart�ales,s ��id,. dis�lQSing party who xelies
<br />upon this instrument from any liability under conf dentialitX �,tles arising. under �IIPAA as a
<br />consequence of said disclosure. I authorize my attorney-i�l-fact wto �execute �ny,and al,l releases or
<br />other documents that may be necessary in order to obtain disclQ�siire ,of ,my patient records and
<br />other medical information subject to and �rotected by HIP�,�. �"Tl�e �4urpose of �e,.foregoing
<br />authorization is to ena.ble my attomey-in-fact to establish that, ,�}S .�ow�x of attoiney is m effect.
<br />. _.,.� � 1 , ' - �- � -
<br />It is my desire and request that no guardia� ,�x� ;cQns�z�yator-. of naX person ar
<br />property be appointed in the event of my , disability or. inca����,�!,. ��,�iowever,. a�ia�ardian or
<br />conservator of my person or property is to. be appoint�,d for,��e, ��.,��'�b� ,nominate• and appoint
<br />my attorney-in-fact hereunder to serve as guaxdian and conservaiQ, .�t�iout bond. �" a: -.,. .
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<br />receiving a duly executed co or fas imile of this ow der � e��by �ee that _at�y. thirc� party
<br />To induce an third to act hereun
<br />' py p er of altom�y, �.y_act hereunder and tha.t
<br />revocation or termination hereof sha11 be ineffective as to such t�r�c��p� actual
<br />notice or knowledge of such revocation ox termma.t�on shal�. �.a�g ; b�e���xeceived by_ sueh�third
<br />parly. I, for myself and my heirs, executors, legal represen�t�yes ��?d�-�assigns,. h�re,by,,,agi�ee to
<br />indemnify and hold hazmless any such third party from and ag ' �,az�y,.�and �11 cla'�ms,t,�at may
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