| | | Portability and Accountability Act of 1996, 42 United States | | Code, Section 1320d et seq. and its regulations, 45 Code of | | Federal Regulations 160-164.__The surrogate or agent has all the | | rights of the patient with respect to the use and disclosure of | | the individually identifiable health information and other | | medical records of the patient. |
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| | | Sec. C-3. 18-A MRSA §5-804, Pt. 1, as enacted by PL 1995, c. 378, Pt. | | A, §1, is amended to read: |
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| | | POWER OF ATTORNEY FOR HEALTH CARE |
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| | | (1) DESIGNATION OF AGENT: I designate the following | | individual as my agent to make health-care decisions for me: |
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| | | ....................................................... |
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| | | (name of individual you choose as agent) |
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| | | ....................................................... |
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| | | (address) (city) (state) (zip code) |
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| | | ....................................................... |
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| | | (home phone) (work phone) |
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| | | OPTIONAL: If I revoke my agent's authority or if my agent is | | not willing, able or reasonably available to make a health-care | | decision for me, I designate as my first alternate agent: |
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| | | ....................................................... |
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| | | (name of individual you choose as first alternate agent) |
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| | | ....................................................... |
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| | | (address) (city) (state) (zip code) |
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| | | ....................................................... |
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| | | (home phone) (work phone) |
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| | | OPTIONAL: If I revoke the authority of my agent and first | | alternate agent or if neither is willing, able or reasonably | | available to make a health-care decision for me, I designate as | | my second alternate agent: |
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| | | ....................................................... |
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| | | (name of individual you choose as second alternate agent) |
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| | | ....................................................... |
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| | | (address) (city) (state) (zip code) |
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| | | ....................................................... |
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