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<br />involving my federal, state, local or foreign taxes at such address as my attorney-in-fact may
<br />designate.
<br />This power of attorney sha11 take effect upon my becoming physically disabled,
<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 esta.blish 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 />Portability and Accountability Act of 1996, the regulations in 45 C.F.R Sec. 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 all health, medical and
<br />fmancial information and any information or records referred to in 45 C.F.R Sec. 164.501 and
<br />regulated by the 5tandazds 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 vuus_�HIV�, bel�aviqral o�m�ntalhealth.services,
<br />and treatment for alcohol or drug abuse or addiction. I understand� t�ia.t 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 the. d�scl�,Sure, of .tbi.srhe,�lth ,in�ormarion� is
<br />voluntary and that I can refuse to sign this authorization. I�ex u4ndersta;n,d.that aziy discloaure
<br />of this information carries with it the potential for an una��'o�,zed� fiirtfier disclosure of this
<br />information by third parties and that such further disclosure may not be protected under HII'AA.
<br />In order to induce the disclosing party ,to disclose�. the.,.a�fQx�e�a _pri�ate _anc�l�r .protected
<br />confidential information, I forever release and hold harmle�s ��ud,�,.diis�lQSing party who �elies
<br />upoa this instrument from any liability under confidentialitX rul�s `arising. under �IIPAA as a
<br />consequence of said disclosure. I authorize my attomey-in-fact;to �execute. �ny,and �,ll releases or
<br />other documents that may be necessary in order to obtain disclQ�ure , of ,my patient records and
<br />other medical information subject to and �rotected by HIPA.t� �;�T�,� �,uipose of �e, foregoing
<br />authorization is to ena.ble my attomey-in-fact to esta.blish that, �}s .�ow�r of attorney is in effec�
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<br />It is my desire and request that na guardi �a� ,o�r� cQnseivator-. of �X ; per�on or
<br />property be appointed in the event of my , disability or. inca���,��!. r � .�iowever, . a�uardian or
<br />conservator of my person or property is to, be appointed for, �„��'�b� ,nominate .and appoint
<br />my attomey-in-fact hereunder to serve as guardian and conservat,p.�;v�thQut bond. "' N � -.,. .
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<br />To induce any third party to act hereunder ��e��by �ee that.anyi third party
<br />receiving a duly executed copy or facsimile of this power of altom�y, �x_act hereunder, and that
<br />revocation or termination hereof sha11 be ineffective as to such t�ir`c� �p�arty� ��ss aticl: unt�l .actual -
<br />notice or knowledge of such revocation oz termination sha1�, �ayg l b�e��iieceived by. sueh`third
<br />party. I, for myself and my heirs, executors, legal representat�ves r a,nd B assigns ; .la�,r,��y,agree to
<br />indemnify and hold harmless any such third party from and a��i�st.aac},y �,11 that may
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