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A University of Alabama Law School Clinical Program funded in part by West Alabama Regional Commission

Advance Health Care Decisions

Powers of Attorney

Wills, Trusts, Estates


Long Term Care Financing

Income Assistance

Nursing Home Issues

Other Consumer Issues:

Insurance (non-health)
Credit Cards
Identity Theft


Pursuant to 45 CFR § 164.508 (b) and (c), I, ______________________, hereby authorize the person or persons named to review, copy, discuss, release and generally to have access to my personally identifiable health and related information as indicated below:

1. Person(s) authorized:
Name: ________________________________
Address: ______________________________
Name: ________________________________
Address: _______________________________

2. Information to be released:
The person(s) named above is/are authorized to access,
view and copy, and covered entities are authorized to provide them access, to: Any and all health , health care and related information of all kinds and in any form.

3. Purpose:
The described information shall be released at the request of those named above, as may be needed to assist in my treatment and care, to make health care decisions, and for any other reason at the discretion of the said designee(s).

4. Expiration, right to revoke:
This authority shall continue until my death unless earlier revoked by me, and I understand that I may revoke it at any time.

5. Non-liability of provider:
Once the requested information is disclosed to the person(s)
I have designated, the provider shall have no liability for any redisclosure of the Information by the recipient.

I am signing this document on the _______ day of ________________, 200___.
I have read it, I understand it and I am signing it voluntarily, with the intention that the person(s) named shall have the same access to my personally identifiable health care and related information as I have myself.

Signature of Grantor: ____________________________
Name typed or printed: ___________________________
Witness: ________________________

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