Free HIPAA Power of Attorney Template
HIPAA POWER OF ATTORNEY
This HIPAA Power of Attorney ("Document") is made effective as of [Date], by and between [Your Name], with a mailing address of [Your Company Address] (hereinafter referred to as "Principal"), and [Agent's Full Name], with a mailing address of [Agent's Address] (hereinafter referred to as "Agent").
I. Purpose of the Document
This Document is created to grant the Agent the authority to access the Principal's Protected Health Information (PHI) as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and any subsequent amendments thereto. The purpose of this document is to ensure that the Agent can make informed decisions regarding the Principal's health care in situations where the Principal is unable to make decisions for themselves.
II. Grant of Powers
The Principal hereby grants the Agent the following roles and responsibilities:
a. Access to Protected Health Information (PHI):
The Agent shall have full authority to request, access, and review all of the Principal's PHI for any purpose permitted under HIPAA regulations.
b. Disclosure of Information:
The Agent is authorized to give and receive PHI as necessary to implement the Principal's healthcare decisions, including but not limited to discussions with healthcare providers and insurance companies.
c. Decision Making:
In the event the Principal is unable to make healthcare decisions, the Agent is granted the authority to make such decisions on the Principal's behalf, utilizing the Principal's PHI to inform these decisions.
d. Authorization to Release Information:
The Agent shall have the authority to authorize the release of the Principal's PHI to third parties as required for the Principal's health care management and legal matters.
e. Amendment or Revocation of Prior PHI Releases:
The Agent is authorized to amend or revoke any prior authorizations for the use or disclosure of PHI as the Agent deems necessary for the Principal's welfare.
III. Duration
This Document shall remain in effect indefinitely from the date of its execution unless revoked or terminated by the Principal or upon the Principal's death.
IV. Revocation
The Principal retains the right to revoke this HIPAA Power of Attorney at any time, provided such revocation is made in writing and delivered to the Agent.
V. Governing Law
This Document shall be governed by the laws of the State of [State], without regard to its conflicts of law provisions.
In witness whereof, the Principal and the Agent have executed this HIPAA Power of Attorney as of the Effective Date.
Principal:
[Your Name]
Agent:
[AGENT'S NAME]
Witness Acknowledgement
I, [Witness Name], residing at [Witness Address], hereby acknowledge that the Principal, [Your Name], has signed this HIPAA Power of Attorney in my presence on the date written below.
Witness:
[WITNESS NAME]
Notary Acknowledgement
State of
County of
On this day of , 20, before me, a notary public personally appeared [Your Name] and [Agent's Full Name], known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within the instrument and acknowledged that they executed the same for the purposes therein contained.
Witness my hand and official seal.
[NOTARY PUBLIC'S NAME]
My Commission Expires:
