otherwise private health care information, and I authorize covered
entities to provide to ____________________, the same access to
them and cooperation with them to which I am entitled myself.]
LIMITATIONS ON AGENT'S AUTHORITY
An agent that is not my ancestor, spouse, or descendant MAY NOT use my
property to benefit the agent or a per-son to whom the agent owes an
obligation of support unless I have included that authority in the Special
Limitation of Power. Except for any special instructions given herein to the
agent to make gifts, the following shall apply:
(a) Any power or authority granted to my Agent herein shall be limited so as
to prevent this Power of Attorney from causing any Agent to be taxed on my
income or from causing my assets to be subject to a "general power of
appointment" by my Agent as defined in 26 U.S.C. Section 2041 and 26
U.S.C. Section 2514 of the Internal Revenue Code of 1986, as amended.
(b) My Agent shall have no power or authority whatsoever with respect to
any policy of insurance owned by me on the life of my Agent, or any trust
created by my Agent as to which I am a trustee.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines. For your protection,
if there are no special instructions write NONE in this section.
NOMINATION OF [CONSERVATOR OR GUARDIAN] (OPTIONAL)
If it becomes necessary for a court to appoint a [conservator or guardian] of
my estate or [guardian] of my person, I nominate the following person(s) for