Laserfiche WebLink
. <' <br />�0120'788� <br />consent and directions made by my attorney-in-fact under the <br />authority contained in this document. In consideration of the <br />medical provider's reliance upon the actions of my attorney-in- <br />fact, I hereby contract to defend, indemnify and save harmless <br />any medical provider who does so rely of and from any and alI <br />claims, demands, suits and causes of action which arise from that <br />provider's acts or failures to act as a result of that reliance <br />and brought by me or on my behalf or by any person claiming by, <br />through or under me or as a result of my death. This contract is <br />and shall be fully binding upon my heirs, personal <br />representatives and my estate. <br />I authorize and request any physician, health care <br />professional, health care provider and medical care facility to <br />provide to my Agent information requested by my Agent relating to <br />my physical and mental condition and the diagnosis, prognosis, <br />care and treatment thereof. By this authorization my designated <br />Agent sha11 be considered as my personal representative under <br />privacy regulations related to protected health information and <br />my designated Agent shall be entitled to all health information <br />in the same manner as if I personally were making the request. <br />This authorization and request shall also be considered a consent <br />to the release of such information under current laws, rules and <br />regulations as well as under future laws, rules and regulations <br />and amendments to such laws, rules and regulations including, but <br />not be limited to, the express grant of authority to personal <br />representatives as provided by Regulation Section 164.502(g) of <br />Title 45 of the Code of Federal Regulations and the medical <br />information privacy law and regulations generally referred to as <br />HIPPA. <br />LONG TERM CARE <br />At the present time I am in good health and able to care for <br />myself. I desire to remain in my own home and under my own care <br />as long as I can do that without causing danger of personal harm <br />to myself or others. I direct that my Agent shall have the <br />exclusive power and authority to decide if and when I should be <br />moved into a long term care facility, as well as the power and <br />authority to select that long term care facility. I request my <br />Agent to have me seen by and to obtain the opinion and advice of <br />my personal physician concerning that decision and I authorize my <br />personal physician to communicate to my Agent any and all <br />information which might otherwise be confidential or privileged <br />information concerning me. <br />3 <br />