Fill and Sign the New Patient Forms Augusta Oncology

Prepared by, recording requested by and return to: Name: __________________________________________________________ Address: ________________________________________________________ City: _________________________________________ State: ________________________________________ Zip: _______________________ Phone: _______________________ Fax: ______________________________________NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT, WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST ACT IN ACCORDANCE WITH YOUR REASONABLE EXPECTATIONS TO THE EXTENT ACTUALLY KNOWN BY YOUR AGENT AND, OTHERWISE, IN YOUR BEST INTEREST, ACT IN GOOD FAITH AND ACT ONLY WITHIN THE SCOPE OF AUTHORITY GRANTED BY YOU IN THE POWER OF ATTORNEY. THE LAW PERMITS YOU, IF YOU CHOOSE, TO GRANT BROAD AUTHORITY TO AN AGENT UNDER POWER OF ATTORNEY, INCLUDING THE ABILITY TO GIVE AWAY ALL OF YOUR PROPERTY WHILE YOU ARE ALIVE OR TO SUBSTANTIALLY CHANGE HOW YOUR PROPERTY IS DISTRIBUTED AT YOUR DEATH. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD SEEK THE ADVICE OF AN ATTORNEY AT LAW TO MAKE SURE YOU UNDERSTAND IT. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. Date: _______________________________ ______________________________Principal _______________________________ Print Name AGENT’S ACKNOWLEDGMENT I, _______________________________, have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that when I act as agent: I shall act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, act in good faith and act only within the scope of authority granted to me by the principal in the power of attorney. Date: _______________________________ __________________________Agent _______________________________ Print Name STATE OF PENNSYLVANIA COUNTY OF _______________________________ COMMONWEALTH OF PENNSYLVANIA KNOW ALL MEN BY THESE PRESENT: That I, _______________________________ (Name of Principal), an adult resident citizen of _______________________________ (Name of County) County, Pennsylvania, residing at _______________________________ (Address and Name of where Principal presently resides) have made, constituted and appointed, and by these presents do make, constitute and appoint, _______________________________ (Name of Agent) my true and lawful agent to act as follows, that is to say: 1. To act for me and in my name, place and stead to ask, demand, sue for, collect and receive all sums of money, dividends, interest, payments on account of debts and legacies and all property now due or which may hereafter become due and owing to me, and give good and valid receipts and discharges for such payments; stead to ask, demand, sue for, collect and receive all sums of money, dividends, interest, payments on account of debts and legacies and all property now due or which may hereafter become due and owing to me, and give good and valid receipts and discharges for such payments; 2. To retain counsel and attorneys on my behalf, to appear for me in all actions and proceedings to which I may be party in the courts of Pennsylvania or of any other state in the United States, or in the United States courts, to commence actions and proceedings in my name if necessary, to sign and verify in my name all complaints, petitions, answers and other pleadings of every description; 3. To demand, collect, recover, sue for, receive and give receipt or release for any monies, debts, dividends, interests, royalties, legacies, annuities, demands, discounts, income, rents, profits, securities or other property of any sort, now or hereafter due or becoming due to me or to which I may be or hereafter become entitled; 4. To endorse and negotiate for any and all purposes all promissory notes, checks, drafts or other negotiable or non-negotiable paper payable to me or to my order; 5. To deposit in my attorney's or my name, or jointly in both our names, in any banking institution, funds or property, and to withdraw any part or all of my deposits at any time made by me in my behalf. 6. To institute, maintain, defend, compromise, arbitrate or otherwise dispose of, any and all actions, suits, attachments or other legal proceedings for or against me. FURTHER, I do authorize my aforesaid attorney to execute, acknowledge and deliver any instrument under seal or otherwise, and to do all things necessary to carry out the intent hereof, hereby granting unto my said attorney full power and authority to act in and concerning the premises as fully and effectually as I may do if personally present. PROVIDED, however, that all business transacted hereunder for me or for my account shall be transacted in my name, and that all endorsements and instruments executed by my said attorney for the purpose of carrying out the foregoing powers shall contain my name, followed by that of my said agent and the designation "agent-in-fact". This Power of Attorney shall not be affected by any subsequent disability or incompetence. I further declare that any act or thing lawfully done hereunder by my said attorney shall be binding on myself and my heirs, legal and personal representatives and assigns, whether the same shall have been done either before or after my death, or other revocation of this instrument, unless and until reliable intelligence or notice thereof shall have been received by my said attorney. FURTHER, I direct that my Agent-in-fact shall have, in addition to the powers set out above, all powers specified in Tile 20, Chapter 56, Section 5602, Pennsylvania Consolidated Statutes, all to be carried out for my benefit, including the power: 1. To create a trust for my benefit. 2. To make additions to an existing trust for my benefit 3. To disclaim any interest in property. 4. To withdraw and receive the income or corpus of a trust. 5. To engage in tangible personal property transactions. 6. To engage in banking and financial transactions. 7. To enter safe deposit boxes. 8. To pursue claims and litigation. IN WITNESS WHEREOF, I have hereunto set my hand and seal this the ________ day of _______________________________, 20____. _______________________________ (Printed Name of Principal)______________________________ (Signature of Principal)ATTESTATION OF WITNESSES The hereinafter named Witnesses, each declare under penalty of perjury under the laws of the State of Pennsylvania, that the principal is personally known to us, that the principa l signed and acknowledged this special power of attorney in our presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that we are not the person appointed as attorney-in-fact by this document and that we witnessed this power of attorney in the presence of the principal. We are 18 years of age or older and not the individuals who signed the power of attorney on behalf of and at the direction of the principal, or the notary public , or other person authorized by law to take acknowledgments before whom the power of attorney is acknowledged We are not related to the principal by blood, marriage or adoption, and to the best of our knowledge, are not entitled to any part of the estate of the principal upon the de ath of the principal under a will now existing or by operation of law. _______________________________ Signature_______________________________ Printed Name _______________________________ Address _______________________________ Signature_______________________________ Printed Name_______________________________ Address STATE OF PENNSYLVANIA COUNTY OF _______________________________ On this ________ day of _______________________________, ________, before me, ____________________, the undersigned officer, personally appeared _______________________________ known to me to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal.____________________________ NOTARY PUBLIC My Commission Expires:______________________