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201207312
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Last modified
9/10/2012 2:55:09 PM
Creation date
9/4/2012 9:27:19 AM
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DEEDS
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201207312
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20�20731� <br />appoint a guardian of my estate, I nominate the person designated as my Agent to serve <br />as Guardian and if s/he is unwilling or unable to serve as Guardian, I nominate my <br />alternate Agent above named. <br />If someone other than my first above-named Agent ("primary Agent") is <br />appointed as Guardian or Limited Guardian of my estate, my primary Agent shall have <br />the power and authority when s/he is competent, willing and able to act as Guardian to <br />petition the Court to discharge my then appointed Guardian or Limited Guardian, and <br />s/he shall he so appointed by the Court, unless the Court finds good cause against her/his <br />appointment. <br />F. Conrt Enforcement. My Agent shall have the power to seek appropriate <br />court orders mandating acts which my Agent deems appropriate if a third party refuses to <br />comply with decisions made by my Agent which are authorized by this document, or <br />enjoining acts by third parties which my Agent has not authorized. My Agent may bring <br />legal action against any third parly who fails to comply with actions I have authorized my <br />Agent to take and demand damages on my behalf for such noncompliance. <br />G Reliance On Phot�opy. Third parties shall he entitled to rely on a <br />photocopy of the signed Original hereof. <br />H. Applicable Law. The laws of the State of Nebraska shall govern this <br />Power of Attorney. This Power of Attorney is intended to be valid in any jurisdiction in <br />which it is presented. <br />I. HIPAA Release Anthority. I intend for my agent to be treated as I <br />would be with respect to my rights regazding the use and disclosure of my individually <br />identifiable health information or other medical records. This release authority applies to <br />any information govemed by the Health Insurance Portability and Accountability Act of <br />1996 (aka Hg'AA), 42 USC 1320d and 45 CFR 160-164.I authorize: any physician, <br />health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or <br />other covered health-care provider, any insurauce company and the Medical Information <br />Bureau Inc. or other health-care clearinghouse that has provided treatrnent or services to <br />me, or that has paid for or is seeking payment from me for such services, to give, disclose <br />and release to my agent, without restriction, all of my individually identifiable health <br />information and medical records regarding any past, present or future medical or mental <br />health condition, including all information relating to the diagnosis and treatment of <br />HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. <br />The authority given my agent shall supersede any prior agreement that I may have <br />made with my health-care providers to restrict access to or disclosure of my individually <br />identifiable health information. The authority given my agent has no expiration date and <br />shall expire only in the event that I revoke the authority in writing and deliver it to my <br />health-care provider. <br />DPOAF of Bill D. Schultz Page 15 of 17 Initials: � Date: �—� <br />
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