(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated.

(6) HEALTH INFORMATION AND OTHER MEDICAL RECORDS: In addition to the other powers granted by this document, I grant to my agent the power and authority to serve as my personal representative for all purposes of the federal Health Insurance Portability and Accountability Act of 1996, 42 United States Code, Section 1320d et seq., "HIPAA," and its regulations, 45 Code of Federal Regulations 160-164, during any time that my agent is exercising authority under this document. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information and other medical records. This release authority applies to any information governed by HIPAA.

I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and any health-care clearinghouse that has provided treatment or services to me or that has paid for, or is seeking reimbursement from me for, such services to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse.

The authority given to my agent supersedes any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given to my agent has no expiration date and expires only in the event that I revoke the authority in writing and deliver it to my health-care providers.