.......................................................

.......................................................

.......................................................

(Add additional sheets if needed.)

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions unless I mark the following box. If I mark this box [ ], my agent's authority to make health-care decisions for me takes effect immediately.

(4) AGENT'S OBLIGATION: My agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(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, Section 160-164 (2004), 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