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202109300 ( ___ ) 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 riehts of survivorship ( ) Create or change a lxneficiary designation ( ) Delegate to another person to exercise the authority granted under this power of attorney ( ) Waive the principal's right to be a beneficiary (if a joint and survivor annuity:. including a survivor's benefit under a retirement plan 1 ) Exercise fiduciarypower; that the principal has the authority to delegate ( ) Renounce or disclaim an interest in property, including a power of appointment LIMITATION ON AGENTS AUTHORITY An Agent that is not my ancestor, spouse or descendent 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 -Ibis power of attorney is a durable power of attorney, and it shrill not he affected by my becoming disabled, incompetent or incapacitated. It is my intent that the authority conferred herein shall be exercithle notwithstanding my physical disability or mental incompetence. This power of attorney. however. shall terminate on December 31. 2022. It may be necessary for my agent to have access to my medical records to establish whether medical bilk are valid and appropriate or for other purposes. 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 ct seq., and any other applicable federal. state or local laws or regulations (collectively "I (IPAA"), including the authority to request, receive, obtain and review. and be granted full and unlimited access to, and consent to the disclosure of complete unredactod copies of any and all health, medical and financial in fonnation and arty information or records referred to in 45 C.F.R. Sec. I 64.501 and regulated by the Standards for Privacy of Individually Idattifiable 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 immunodenciency syndrome (Ain') AIDS-related complex (ARC) and human immunodeficiency virus (HIV). behavioral or mental health services, and treatment kr alcohol or drug abuse or addiction. I understand that I may have access to or receive an accounting of the information to he used or disclosed as provided in 45 C.F.R. See. 164.524 et seq. 1 further understand that authorizing the disclosure of this health information is voluntary,' and that I can refuse to sign this authorization. 1 further understand that any disclosure of this information carries with it the potential fir an unauthorised further