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201906669 ( ) Create, amend, revoke or terminate an inter vivos trust ( ) Make a gift, subject to the limitations of the Uniform Power of Attorney Act and any special instructions in this power of attorney ( ) Create or change rights of survivorship (__ _) Create or change a beneficiary designation ( ) Delegate to another person to exercise the authority granted under this power of attorney ( ) Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan ( ) Exercise fiduciary powers that the principal has the authority to delegate ( ) Renounce or disclaim an interest in property, including a power of appointment LIMITATION ON AGENT'S AUTHORITY An Agent MAY NOT use my property to benefit the agent or a person to whom the agent owes and obligation of support unless I have included that authority in the Special Instructions. SPECIAL INSTRUCTIONS This power of attorney shall take effect upon my becoming physically disabled, mentally incompetent or otherwise incapacitated. Any third party may rely upon the written declaration of my agent that such contingency has occurred. It may he necessary for my agent to have access to my medical records to establish that this power of attorney is in effect. I grant to my agent the authority and power to serve as my personal representative for all purposes of the Health Insurance Portability and Accountability Act of 1996, the regulations in 45 C.F.R. Sec. 160 et seq., and any other applicable federal, state or local laws or regulations (collectively "HIPAA"), including the authority to request, receive, obtain and review, and he granted full and unlimited access to, and consent to the disclosure of complete unredacted copies of any and all health, medical and financial information and any information or records referred to in 45 C.F.R. Sec. 164.501 and regulated by the Standards for Privacy of Individually Identifiable health Information found in 65 Fed. Reg. 82462 as protected private records or otherwise covered under HIPAA. I understand that health and medical records can include information relating to subjects such as sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), AIDS-related complex (ARC) and human immunodeficiency virus (HIV), behavioral or mental health services, and treatment for alcohol or drug abuse or addiction. I understand that I may have access to or receive an accounting of the information to be used or disclosed as provided in 45 C.F.R. Sec. 164.524 et seq. I further understand that authorizing the disclosure of this health