Sample Healthcare Proxy Form - Massachusetts

3
appointed Healthcare Agent and alternate Healthcare Agent for appoint-
ment by such court to serve as such fiduciary.
D. HIPAA RELEASE AUTHORITY
I hereby grant my Healthcare Agent release authority that applies to any
information governed by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d, as now in effect, and
as such law may from time to time hereafter be amended. I intend that my
Healthcare Agent be treated as I would be, with respect to my rights regard-
ing the use and disclosure of my individually identifiable health informa-
tion and/or other medical records.
I hereby authorize any physician, healthcare professional, dentist,
health plan, hospital, clinic, laboratory, pharmacy, or other covered health-
care provider, any insurance company or healthcare clearinghouse that has
provided treatment or services to me, that has paid for or that is seeking
payment from me for such services, to give, disclose and release to my
Healthcare Agent, without restriction, all of my individually identifiable
health information and medical records regarding any past, present or
future medical or mental health condition.
The authority given to my Healthcare Agent under this Section D
supercedes any prior agreement that I may have made with my healthcare
providers with respect to disclosure of my individually identifiable health
information.
As long as this Healthcare Proxy remains in full force and effect, the
HIPAA release authority given under this Section D has no expiration date
and shall expire only in the event that I revoke the authority in writing and
deliver it to my healthcare provider.
E. REVOCATION
This Healthcare Proxy shall be revoked upon any one of the following
events:
a. my execution of a subsequent Healthcare Proxy
b. my divorce or legal separation from my spouse where my spouse is
named as my Healthcare Agent
c. my notification to my Healthcare Agent or a healthcare provider orally
or in writing or by any other act evidencing a specific intent to revoke
the Healthcare Proxy
SIGNATURE OF PRINCIPAL
I hereby sign my name on this _______ day of _____________________,
_____, to this Healthcare Proxy in the presence of two witnesses.
______________________________ Client Name
Appendix G: Sample Healthcare Proxy Form 513
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Sample Healthcare Proxy Form - Massachusetts PDF

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