Fill and Sign the Provider Update Form Dentaquest

Prepared by, recording requested by and return to: Name: Company: Address: City: State: Zip: Phone: Fax: ----------------------Above this Line for Official Use Only--------------------- The information above is provided in the event this form is to be recorded. LIMITED POWER OF ATTORNEY STATE OF MISSOURICOUNTY OF ___________________________ KNOW ALL MEN BY THESE PRESENT, THAT I ___________________________,whose address is ___________________________, ___________________________ (City), _________ (State), _________ (Zip), desiring to execute a SPECIAL POWER OF ATTORNEY, hereby appoint, ___________________________, of___________________________ County, Missouri, as my Attorney-in-Fact to act as follows, GRANTING unto my Attorney-in-Fact full power to: Insert powers here. See examples at the end of this form___________________________________________________________________________________________________________________________________________________________________________ FURTHER, I do authorize my aforesaid attorney-in-fact 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-in-fact full power and authority to act in and concerning the premises as fully and effectually as I may do if personally present, limited, however, to the purpose for which this limited power of attorney is executed. 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-in-fact for the purpose of carrying out the foregoing powers shall contain my name, followed by that of my said attorney and the designation "attorney-in-fact". I further declare that any act or thing lawfully done hereunder and within the powers herein stated 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
birth. (signature page attached) (signature attached) (the names of the person and their attorneys are also attached.) (signature attached to above) (this document indicates that the legal heirs of the parties have entered, with their names and other identifying information, the original power of attorney. ) this document indicates that the legal heirs of the parties have entered, with their names and other identifying information, the original power of attorney. (signature attached to above) i hereby declare under penalty of perjury that when this document is properly signed, sealed and delivered, all of the following facts are true and accurate: the foregoing power of attorney was executed by my (legal heir of parties named) attorney-in-fact, or attorney for me of his or her own choosing, as the case may be. I am the legal heir of the parties named, to the extent that I have the right to have actual knowledge of my legal authority as heir through the death or incapacity of my legal heir. I, at the date of execution, have power to direct all financial, legal and any other matters required by my powers under my limited power of attorney. I understand that i shall be responsible for all expenses incurred as a result of executing the limited power of attorney, in addition to any other expense that my legal heir (legal heir means legal heir under state law) may incur. I am making this declaration for both good and benefit of myself and my intended heirs, legal and other representatives, and assigns, to the extent that these declarations may extend to me or the legal heirs of such legal heirs under law. I have read the foregoing power of attorney, and upon its face, accept these conditions. (signature attached to above)