Questionnaire - Ancillary Documents

For use in preparation of powers of attorney, health care proxies and HIPAA authorizations

Date *

INFORMATION ABOUT INDIVIDUAL FOR WHOM DOCUMENTS ARE BEING PREPARED

Name of individual completing this form *

Name of Individual for whom documents are being prepared *

Pronouns for the Individual whom the documents are being prepared

Home address *

Telephone number

Date of birth

Preferred Modes of Communication

Text
Phone
Email
Message through secure portal

POWER OF ATTORNEY - The power of attorney allows an individual to appoint an agent to handle his or her financial affairs.

Full name of agent to be appointed *

Pronouns of agent

Home address of agent *

Telephone number of agent

Would you like to provide the agent with a HIPAA authorization so that the Individual's health care provider can share the Individual's medical information with the agent? *

Yes
No

Full name of successor agent (if any) if first agent unable to act

Pronouns of successor agent

Home address of successor agent

Telephone number of successor agent

Would you like to provide the successor agent with a HIPAA authorization so that the Individual's health care provider can share the Individual's medical information with the successor agent?

Yes
No

HEALTH CARE PROXY - The health care proxy allows an individual to appoint an agent to make health care decisions in the event the individual is unable to do so.

Would you like the same agent(s) named under the power of attorney to serve as agents under the health care proxy? *

Yes
No; please see below

Full name of agent to be appointed (if not same as above)

Pronouns of agent to be appointed (if not same as above)

Home address of agent

Telephone number of agent

Full name of successor agent to be appointed (if not same as above)

Pronouns of successor agent to be appointed (if not same as above)

Home address of successor agent

Telephone number of successor agent

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Please fill in all the required fields before submitting this form.