Healthcare Management Execution

HEALTHCARE MANAGEMENT EXECUTION

Parties and Effective Date

Patient Name:

Designated Healthcare Manager (Agent) Name:

Manager Contact (phone/email):

Effective Date:

Declaration and Authority

I, the undersigned Patient, hereby appoint the designated Healthcare Manager named above to act on my behalf with respect to my medical care and related administrative matters. This appointment is voluntary and is made while I am competent to do so. I specifically grant the Healthcare Manager the authority set forth below.

Scope of Authority (select all authorities granted):

Access and obtain copies of my medical records and protected health information.

Consent to, refuse, or withdraw consent for medical treatment on my behalf, including diagnostic, therapeutic, and surgical procedures consistent with my expressed wishes.

Arrange, admit, transfer, or discharge me from hospitals, skilled nursing facilities, rehabilitation, or other care settings.

Make decisions regarding life-sustaining treatment and palliative care consistent with my expressed wishes and any advance directives I have executed.

Communicate and coordinate with my insurers and benefit administrators for authorizations, claims, and coordination of benefits related to medical care.

Limitations and Restrictions

The Healthcare Manager shall not have authority to make financial decisions unrelated to the direct provision or authorization of medical care, unless such authority is expressly conferred in a separate written instrument. The Healthcare Manager shall act in good faith and in accordance with my known wishes; where my wishes are unknown, decisions shall be made in my best interest.

HIPAA Authorization and Release of Health Information

I authorize any health care provider, health plan, or health care clearinghouse to disclose my protected health information to the designated Healthcare Manager to the extent necessary for the Manager to carry out the authorities granted by this Healthcare Management Execution. This authorization includes disclosure of medical records, test results, treatment plans, and billing information.

I understand that I may revoke this authorization at any time by providing written notice to my health care providers and the Healthcare Manager. Revocation is not effective to the extent that a provider or other party has acted in reliance on this authorization prior to receipt of the revocation.

Authorization Expiration Date:

Patient Information

Male Female Other / Prefer not to say

Insurance and Provider Information

Medical History and Current Status

Acknowledgments, Revocation, and Certification

Revocation: I may revoke this Healthcare Management Execution at any time by providing written notice to the Healthcare Manager and my health care providers. Revocation does not affect actions taken in reliance prior to receipt of written revocation.

Reliance: Health care providers and other third parties may rely upon a copy or facsimile of this document as if it were the original. I release providers from liability for disclosures made in good faith pursuant to this execution.

Certification of Capacity: By signing below I certify that I am at least eighteen years of age (or legally emancipated) and am of sound mind and legal capacity to execute this instrument. If I am signing as a legal guardian or other lawful representative, I certify that I have the authority to make health care decisions for the patient named herein.

If Signing as Representative:

I am signing on behalf of the patient as their legal guardian or authorized representative.

Optional Manager Acknowledgment

The Healthcare Manager may acknowledge acceptance of appointment by completing the acknowledgment below. Acceptance is not required for the validity of this appointment; however, acceptance indicates the Manager's willingness to assume the duties described herein.

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