12 . Nomination of Guardian
If , after execution of this Durable Power of Attorney for Healthcare , incompetency proceedings are initiated either for my estate or my person , I hereby nominate as my guardian or conservator for consideration by the court my agent herein named , in the order named .
13 . Release of Information
I agree to , authorize and allow full release of information by any government agency , medical provider , business , creditor or third party who may have information pertaining to my healthcare , to my agent named herein , pursuant to the Health Insurance Portability and Accountability Act of 1996 , Public Law 104-191 , as amended and applicable regulations .
You must date and sign this Power of Attorney . I sign my name to this Durable Power of Attorney for Healthcare on ______________________________________ ( date ) at __________________________ ( city ), ____________ ( state ) __________________________________________ ( signature ).
This Power of Attorney will not be valid for making healthcare decisions unless it is either ( 1 ) signed by at least two qualified witnesses who are personally known to you and who are present when you acknowledge your signature , or ( 2 ) acknowledged before a notary public .
-8-