Health Care Power Of Attorney Form - South Carolina (Page 3 of 7) in pdf

SOUTH CAROLINA HEALTH CARE POWER OF

ATTORNEY

1. DESIGNATION OF HEALTH CARE AGENT

I, ____________________________________________________________, hereby appoint:

(Principal)

(Agent's Name) ____________________________________________________________

(Agent's Address) ____________________________________________________________

Telephone: home: ________________ work: __________________ mobile:______________

as my agent to make health care decisions for me as authorized in this document.

Successor Agent: If an agent named by me dies, becomes legally disabled, resigns, refuses to act,

becomes unavailable, or if an agent who is my spouse is divorced or separated from me, I name the

following as successors to my agent, each to act alone and successively, in the order named:

a. First Alternate Agent:

Address: ___________________________________________________________________

Telephone: home:________________ work:_________________ mobile:_______________

b. Second Alternate Agent:

Address:___________________________________________________________________

Telephone: home:________________ work:_________________ mobile:_______________

Unavailability of Agent(s): If at any relevant time the agent or successor agents named here are unable

or unwilling to make decisions concerning my health care, and those decisions are to be made by a

guardian, by the Probate Court, or by a surrogate pursuant to the Adult Health Care Consent Act, it is

my intention that the guardian, Probate Court, or surrogate make those decisions in accordance with my

directions as stated in this document.

2. EFFECTIVE DATE AND DURABILITY

By this document I intend to create a durable power of attorney effective upon, and only during, any

period of mental incompetence, except as provided in Paragraph 3 below.

3. HIPAA AUTHORIZATION

When considering or making health care decisions for me, all individually identifiable health

information and medical records shall be released without restriction to my health care agent(s) and/or

my alternate health care agent(s) named above including, but not limited to, (i) diagnostic, treatment,

other health care, and related insurance and financial records and information associated with any past,

present, or future physical or mental health condition including, but not limited to, diagnosis or

treatment of HIV/AIDS, sexually transmitted disease(s), mental illness, and/or drug or alcohol abuse and

(ii) any written opinion relating to my health that such health care agent(s) and/or alternate health care

agent(s) may have requested. Without limiting the generality of the foregoing, this release authority

applies to all health information and medical records governed by the Health Information Portability and

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