Authorization Worksheet

Step 1 of 4

Please complete the following information about yourself.
Name
First Last
Date of Birth
Gender
Permanent Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County
Phone
Email
School (if app.)
Temporary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Temporary County
Marital Status

Please read the descriptions of the various Authorizations below. Each is a standalone permission/directive. Although each has an important, specific purpose, you do not have to sign every document to make the others effective.
Durable Power of Attorney
This form will allow you to appoint an agent, called an “Attorney in Fact” to take any legal or financial action on your behalf. It is valid immediately and continues during a period of incompetency. Only appoint someone you completely trust. Although this document will permit your attorney in fact to handle financial and legal issues, you still have complete control over your own affairs and can revoke the power at any time. Please complete the following regarding the person(s) you wish to grant power over your legal and financial affairs.
Name
First Last
Name
First Last
Relationship
Phone
Email
In conjunction with the named person above, the following individual should have
- EQUAL authority
- SECONDARY authority (only if primary is unavailable or unwilling) to make decisions.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
Power of Attorney for Health Care
This form will allow you to appoint an agent to direct medical care and communicate with doctors and other medical personnel if you are unable to direct your own care. The Attorney-in-Fact has no authority to direct care while you are competent and can direct your own treatment.
Name
First Last
Name
First Last
Relationship
Phone
Email
In conjunction with the named person above, the following individual should have
- EQUAL authority
- SECONDARY authority (only if primary is unavailable or unwilling) to make decisions.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
Have you completed an organ donation registry enrollment form (typically indicated on your driver’s license)?
- Yes
- No

Living Will
This is your specific instruction to your doctor to terminate life support upon a medical determination, confirmed by a second physician, that you are terminally ill, death is imminent, there is no chance for recovery and you are in a vegetative state. It essentially states that if there is no hope of recovery and you are going to die soon from the condition, do not keep you hooked up to machines only to extend your life. Should your living will need to be acted upon, please list the names of the individuals you would like to be notified prior to the physician removing life support.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
In conjunction with the named person above, the following individual should have
- EQUAL authority
- SECONDARY authority (only if primary is unavailable or unwilling) to make decisions.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
HIPAA Release
The Health Insurance Portability and Accountability Act mandates medical privacy. This form allows those appointed to communicate with medical personnel without any patient privacy restrictions. Name the people that you wish to grant authorization to access your medical records and communicate with medical personnel, no matter your medical condition. This form does not give power to direct care.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email

Authorization for Release of Protected Health Information
This form allows all medical providers to specifically release medical records to those named on the form. Name those individuals who may have to obtain medical records on your behalf.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
FERPA
Family Educational Rights and Privacy Act is a federal law that gives protection to student educational records. The student may authorize the release of protected information by completing an authorization. Most colleges and universities will have their own FERPA Authorization Form. As part of this package, we will provide you with an Authorization that has all the data and approvals that are required to release information. THIS FORM IS NOT SCHOOL SPECIFIC. ALTHOUGH IT WILL LIKELY BE ACCEPTED BY MOST SCHOOLS, YOU ARE ENCOURAGED TO CONFIRM THE ACCEPTANCE OF THE FORM WITH THE SCHOOL OR OTHERWISE REQUEST THE SPECIFIC FORM FROM THE SCHOOL.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email
In conjunction with the named person above, the following individual should have
- EQUAL authority
- SECONDARY authority (only if primary is unavailable or unwilling) to make decisions.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Phone
Email

Authorization Worksheet

Step 1 of 4

Please complete the following information about yourself.

Please read the descriptions of the various Authorizations below. Each is a standalone permission/directive. Although each has an important, specific purpose, you do not have to sign every document to make the others effective.

Durable Power of Attorney

Power of Attorney for Health Care

Living Will

HIPAA Release

Authorization for Release of Protected Health Information

FERPA