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HomeMy WebLinkAbout956756COMPREHENSIVE DURABLE POWER OF ATTORNEY BUSINESS AND FINANCIAL MATTERS O KNOW ALL MEN BY THESE PRESENTS: I, David Conroy, 76 E. Hillcrest Drive, Diamondville, Wyoming 83116, hereby designate and appoint Janet Conroy, 76 E. Hillcrest Drive, Diamondville, Wyoming 83116 as my attorney -in -fact, hereinafter referred to as "Agent." My Agent is authorized to do any act that would be lawful for me to do, including but not limited to the following: 1. Filling out, completing, signing and filing federal Internal Revenue Service tax returns; obtaining copies of my federal tax returns from the Internal Revenue Service and representing me in all tax matters with the federal Internal Revenue Service and any other tax agency; 2. Obtaining personal information and confidential information about me and medical records pertaining to me; 3. Handling, supervising and conducting my business, property, investment and financial affairs; 4. Purchasing, selling, leasing and contracting for personal property, service and insurance, including but not limited to changing beneficiaries on life insurance policies owned by me; 5. Receiving money, endorsing checks, cashing checks, drawing checks, opening and closing bank and security accounts, making deposits and withdrawals and accessing safety deposit boxes; purchasing and redeeming certificates of deposit issued by any bank, savings and loan company or stock brokerage company; and purchasing and redeeming any bonds, notes and bills issued by the United States of America; 6. Purchasing and selling stocks and bonds, transferring and assigning stock and bond certificates, executing proxies and exercising voting rights; 7. Contracting for and purchasing real property on my behalf; selling and conveying any interest I hold in real property, wherever located; entering into contracts and rental agreements; borrowing money and incurring expenses; executing notes, mortgages, deeds of trust and other security and credit agreements; and executing, signing, transferring, conveying, assigning and/ or delivering bills of sale, real property deeds and other instruments of title; 1 RECEIVED 11/15/2010 at 3:54 PM RECEIVING 956756 BOOK: 757 PAGE: 233 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 000234 8. Initiating, defending and settling legal claims and lawsuits, and giving releases and indemnities from liability; 9. Hiring persons for assistance in legal, tax, bookkeeping, financial and housing matters; 10. Receiving any money or property that I inherit or that becomes mine due to a right of survivorship, pay on death designation or transfer on death designation; and 11. Applying for any governmental insurance, assistance or Social Security benefits. MEDICAL AND HEALTH CARE MATTERS 12. I designate my Agent, for me, and in my name, place and stead, to authorize medical and psychiatric treatment on my behalf and make and implement health care decisions for me. For purposes of this Comprehensive Durable Power Of Attorney, "health care" and "health care decisions" shall have the meanings set forth in W.S. 35 -22 -402, a copy of which is attached hereto as Exhibit "A" and by this reference is made a part hereof. 13. This power of attorney authorizes Janet Conroy to act for me in all matters of health care decisions and to execute all documents necessary or convenient for the purpose of carrying out my Agent's decisions. It is made pursuant to W.S. 35 -22 -401 et. seq. It is my intent that the authority conferred by this power of attorney instrument shall be exercised notwithstanding my disability. This power of attorney shall become effective immediately and such powers and duties shall remain in full force and effect until my death or until revoked as provided by W.S. 35 -22 -404. 14. I grant to my Agent full authority to make decisions for me regarding my health care. In exercising this authority, my Agent shall follow my desires as stated in this document or otherwise known to my Agent. In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. If my Agent cannot determine the choice I would want made, then my Agent shall make a choice for me based on what my Agent believes to be in my best interests. My Agent's authority to interpret my desires is intended to be as broad as possible. Accordingly, my Agent is authorized as follows: 2 00 ?35 A. To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including (but not limited to) artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation; B. To have access to medical records and information to the same extent that I am entitled to, including the right to disclose the contents to others; C. To authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, psychiatric facility, residential care, assisted living or similar facility or service; D. To contract on my behalf for any health care related service or facility, without my Agent incurring personal financial liability for such contracts; E. To hire and fire medical, psychiatric, social service, and other support personnel responsible for my care; F. To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of (but not intentionally cause) my death; G. To take any other action necessary to do what I authorize here, including (but not limited to) granting any waiver or release from liability required by any hospital, physician, or other health care provider; signing any documents relating to refusals of treatment or the leaving of a facility against medical advice, and pursuing any legal action in my name and at the expense of my estate to force compliance with my wishes as determined by my Agent. 15. No person who relies in good faith upon any representations by my Agent shall be liable to me, my estate, my heirs or assigns, for recognizing the Agent's authority. 16. If a guardian of my person should for any reason be required to be appointed, I nominate my Agent, named above. 3 0 0236 17. A. I revoke any prior power of attorney for health care. B. This power of attorney is intended to be valid in any jurisdiction in which it is presented. C. My Agent shall not be entitled to compensation for services performed under this power of attorney, but shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this power of attorney. D. The powers delegated under this power of attorney are separable, so that the invalidity of one or more powers shall not affect any others. E. My Agent is authorized to obtain personal information and confidential information about me and medical records pertaining to me. In authorizing the release of such health care information I acknowledge the requirements set forth by HIPAA guidelines and specifically acknowledge those certain terms as set forth on Exhibit "B" attached hereto. GIVING AND GRANTING to my Agent full power and authority to execute all documents and to do and perform any and every act and thing whatsoever requisite, necessary or convenient to be done as fully and effectively, and to all intents and purposes, as I might or could do in my own proper person if personally present to achieve the foregoing. I hereby state and ratify that all acts of my Agent shall be binding on myself, my estate, my heirs and assigns. This power of attorney shall become effective immediately and such powers and duties shall remain in full force and effect until my death or until revoked as provided by applicable statutes. It is my intent that the authority conferred by this power of attorney instrument shall be exercised notwithstanding my disability. BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT. (continued on next page) 4 IN WITNESS WHEREOF, I have hereunto set my hand this i_ day of A nlicr 2010. My Commission Expires: q PI I DAVID CONRO The State of Wyoming ii ss. L., County of i In f;(1 t� I, the undersigned, a Notary Public in and for Lh LO (n County in the State of Wyoming, do hereby certify that said David Conroy, personally known to me or satisfactorily proven to be the person described in the foregoing Comprehensive Durable Power Of Attorney and whose name is subscribed and acknowledged thereto, appeared before me this day in person, appeared to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney -in -fact by this document, and that I am not a treating care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. I further certify that I am not related to David Conroy by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of David Conroy under a Will now existing or by operation of law. IN WITNESS WHEREOF, I hereunto set my name and official seal on this, the 15- clay of ®\i on be( 2010. u Om/14 -a Notary Public 5 SAVANNA I.. HAN4;Ir:'3 M1 JM9` I U6LIC COUNTY OF LINCOLN My Commission EY..ONs STATE Of WOO N( s 40.0237 Attachments: W.S. 35 -22 -402 and Authorization Of Disclosure Of Health Care Information pursuant to applicable HIPAA requirements. 35 -22 -402 Definitions. As used in this act: EXHIBIT A STATE OF WYOMING 6002 38 (i) "Advance health care directive" means an individual instruction or a power of attorney for health care, or both; (ii) "Agent" means an individual designated in a power of attorney for health care to make a health care decision for the individual granting the power; (iii) "Artificial nutrition and hydration" means supplying food and water through a conduit, such as a tube or an intravenous line where the recipient is not required to chew or swallow voluntarily, including, but not limited to, nasogastric tubes, gastrostomies, jejunostomies and intraveous infusions. Artificial nutrition and hydration does not include assisted feeding, such as spoon or bottle feeding; (iv) "Capacity" means an individual's ability to understand the significant benefits, risks and alternatives to proposed health care and to make and communicate a health care decision; (v) "Community care facility" means a public or private facility responsible for the day -to -day care of persons with disabilities; (vi) "Emancipated minor" means a minor who has become emancipated as provided in W.S. 14 -1 -201 through 14 -1 -206; (vii) "Guardian" means a judicially appointed guardian or conservator having authority to make a health care decision for an individual; (iv) "Health care" means any care, treatment, service or procedure to maintain, diagnose or treat an individual's physical or mental condition; (v) "Health care decision" means a decision made by an individual or the individual's agent, guardian, or surrogate, regarding the individual's health care, including: (A) Selection and discharge of health care providers and institutions; (B) Approval or disapproval of diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and (C) Directions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care. 000239 (x) "Health care institution" means an institution, facility or agency licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinary course of business; (xi) "Individual instruction" means an individual's direction concerning a health care decision for the individual; (xii) "Physician" means an individual authorized to practice medicine under the Wyoming Medical Practice Act; (xiii) "Power of attorney for health care" means the designation of an agent to make health care decisions for the individual granting the power; (xiv) "Primary health care provider" means any person licensed under the Wyoming statutes practicing within the scope of that license as a licensed physician, licensed physician's assistant or licensed advanced practice registered nurse; (xv) "Primary physician" means a physician designated by an individual or the individual's agent, guardian or surrogate, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility; (xvi) "Reasonably available" means able to be contacted with a level of diligence appropriate to the seriousness and urgency of a patient's health care needs and willing and able to act in a timely manner considering the urgency of the patient's health care needs; (xvii) "Residential care facility" means a public or private facility providing for the residential and health care needs of the elderly or persons with disabilities or chronic mental illness; (xvii) "State" means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico or a territory or insular possession subject to the jurisdiction of the United States; (xix) "Supervising health care provider" means the primary health care provider who has undertaken primary responsibility for an individual's health care; (xx) "Surrogate" means an adult individual or individuals who: (A) Have capacity; OO 24O (B) Are reasonably available; (C) Are willing to make health care decisions, including decisions to initiate, refuse to initiate, continue or discontinue the use of a life sustaining procedure on behalf of a patient who lacks capacity; and (D) Are identified by the supervising health care provider in accordance with this act as the person or persons who are to make those decisions in accordance with this act. (xxi) "This act" means W.S. 35 -22 -401 through 35 -22 -416. (Laws 2005, ch. 161 1.) EXHIBIT B OOH '41 AUTHORIZATION OF DISCLOSURE OF HEALTH CARE INFORMATION By provision of the foregoing Comprehensive Durable Power Of Attorney I hereby authorize you to disclose to Janet Conroy such health care information and /or records she should request regardless of the date thereof in accordance with Paragraph 16.E. above. In regard to such release of information I understand and specifically acknowledge as follows: a. The information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. b. Authorizing the disclosure of this health information is voluntary. I can refuse to sign the foregoing Comprehensive Durable Power Of Attorney and I need not sign same in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. c. I have the right to revoke the Comprehensive Durable Power Of Attorney and this authorization at any time and that if I do so I must revoke this authorization in writing and present such revocation to the health information management department. Said revocation will not apply to information that has already been released in response to this authorization and that such revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. d. The requested information is being provided to the Requestor for use in connection with the foregoing Comprehensive Durable Power Of Attorney and that any disclosure of information carries with it the potential for an unauthorized re- disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the HIM director, privacy officer, or other individual of the health care provider to whom this authorization is provided. e. Unless otherwise revoked, this authorization will expire on the following date, event or condition: upon revocation of the foregoing Comprehensive Durable Power Of Attorney.