Section 3.34 Form of Health Insurance Portability and Accountability Act

• Library: Estate Planning 2013 Forms

of 1996 Authorization

Authorization for Use and Disclosure of Health Information

in Accordance With Health Insurance Portability and

Accountability Act of 1996

1. I, John Doe, residing at ________________, Missouri, born on ________________, authorize all health care providers, including physicians, nurses, and all other persons (including entities) who may have provided, or may be providing, me with any type of health care, to disclose all of my protected health information:

a. to a trustee, or a designated successor trustee, of any trust of which I am a beneficiary or a trustee when asked to do so for the purpose of determining my capacity as defined in the trust;

b. to a person designated as lawful Attorney in Fact in a Durable Power of Attorney signed by me when asked by such designated Attorney in Fact to do so for the purpose of determining whether I am disabled or incapacitated as defined in the Durable Power of Attorney; and

c. to a person designated as lawful Health Care Attorney in Fact in a Durable Power of Attorney relating to health care decisions signed by me when asked to do so for the purpose of determining my capacity to make rational and reasonable decisions regarding my health care.

2. This authorization is intended to provide my health care providers with the authorization necessary to allow each of them to disclose protected health information regarding me to the persons described in the subparagraphs above for the purpose of allowing each of them to make the specified determinations regarding my capacity or disability.

3. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

4. I UNDERSTAND THAT INFORMATION DISCLOSED BY A HEALTH CARE PROVIDER IN ACCORDANCE WITH THIS AUTHORIZATION IS SUBJECT TO REDISCLOSURE AND MAY NO LONGER BE PROTECTED BY THE PRIVACY RULES OF 45 C.F.R. PART 164.

 

5. I understand that this authorization may be revoked by a writing signed by me or by my personal representative.

6. This authorization shall expire three years after my death unless validly revoked before that date.

In witness whereof, I have hereunto set my hand this _____ day of ________________, 20___.

____________________________________

John Doe

State of Missouri )

) ss.

County of )

On this _____ day of ________________, 20___, before me personally appeared John Doe, to me known to be the person described in and who executed the foregoing Authorization, and acknowledged that he executed the same as his free act and deed.

In testimony whereof, I have hereunto set my hand and affixed my official seal the day and year last written above.

___________________________________________

Notary Public

___________________________________________

Print Name

My Commission Expires ______________________

Last Will and Testament of John Doe

I, John Doe, presently a resident of ________________ County, Missouri, make, publish, and declare this to be my Last Will and Testament, and I hereby revoke all my prior Wills and Codicils.

Article I

Expenses, Claims, and Taxes

My Personal Representative is authorized to pay from my residuary estate:

· all expenses incurred in the administration of my estate;

· all claims against my estate, including the expenses of my last illness, funeral, and burial, which are timely presented to and approved by my Personal Representative or are allowed as proper claims by a court of competent jurisdiction; and

· all transfer taxes directly attributable to property includible in my gross estate for federal transfer tax law purposes, without apportionment to or reimbursement from any person who receives, or before my death has received, any such includible property.

My Personal Representative shall make such elections and allocations under the applicable tax laws as my Personal Representative deems advisable, without regard to the relative interests of the legatees and devisees and without liability to any person. No adjustment shall be made between principal and income or in the relative interests of the legatees and devisees to compensate for the effect of any such elections or allocations.

Article II

Tangible Personal Property

Section 1

I give and bequeath those items of my tangible personal property (excluding trade, business, and titled personal property) described in a List to the person or persons designated in the List to receive the item or items, subject, however, to the following provisions:

a. To be effective as, and conclusively presumed to be, a “List,” the document must be a written statement or list that is dated and is either in my handwriting or signed by me, and it must be located within 30 days following my date of death. Any document that does not satisfy the foregoing requirements shall be conclusively presumed not to be a List.

b. If I prepare more than one List and there is a conflict as to the bequest of any item, the bequest of that item in the List bearing the latest date shall control.

C. UNLESS THE LIST SPECIFICALLY PROVIDES OTHERWISE, A BEQUEST BY LIST TO A PERSON WHO DOES NOT SURVIVE ME SHALL LAPSE.

 

d. My Personal Representative shall be fully exonerated from any liability for distribution of an item or items of tangible personal property made over 30 days after my date of death in accordance with the terms of a List.

Section 2

I give and bequeath all my tangible personal property not effectively disposed of by a List, and all my motor vehicles and other titled tangible personal property, but excluding any trade or business tangible personal property, to my wife, Jane Doe, if she survives me, but if she does not, then to ________________, if [he/she] survives me, but if [he/she] does not, this gift and bequest shall lapse and become a part of my residuary estate.

Article III

Residuary Estate

I give, devise, and bequeath my Residuary Estate, being all of my property, wherever situated, not effectively disposed of under the prior provisions of this Will or outside this Will, but expressly excluding any property over which I may have a power of appointment at my death, to my wife, Jane Doe, if she survives me, but if she does not survive me, to my descendants who survive me, by representation, with the exception that if any of my descendants to whom a distribution is to be made has not attained the age of [number] years at the date of distribution, the part shall not be distributed but instead shall continue in trust as a separate trust estate for the primary benefit of the descendant for whom the part is provided, upon the terms subsequently set forth in this Will.

Article IV

Descendant Trust Terms

Each trust created under Article III for the primary benefit of a descendant of mine who has not attained the age of [number] years, and with respect to which the descendant for whose benefit the trust is created shall be referred to in this Article as the “Beneficiary” of the trust estate, shall be separately held and distributed upon the following terms:

Section 1

The Trustee shall have full power and authority from time to time to distribute such amounts of the net income and principal of the trust estate to or for the benefit of the Beneficiary as the Trustee, in the Trustee’s absolute discretion, deems necessary or advisable for the health, education, support, and maintenance of the Beneficiary, subject, however, to the following provisions:

a. The Trustee shall consider other resources known to the Trustee that are available to the Beneficiary for such purposes.

b. A distribution shall not be deemed an advancement.

Any net income derived from the trust estate and not distributed in accordance with the prior provisions of this Section shall be accumulated and periodically added to principal.

Section 2

The principal of the trust estate shall be distributed to the Beneficiary as follows:

a. One-third of the principal then remaining when the Beneficiary attains the age of [number] years, or upon creation of the trust if the Beneficiary has then attained that age.

b. One-half of the principal then remaining when the Beneficiary attains the age of [number] years, or upon creation of the trust, and determined after the distribution under Subsection 2.a, if the Beneficiary has then attained that age.

c. All of the principal then remaining, together with any undistributed net income, when the Beneficiary attains the age of [number] years.

Section 3

If the Beneficiary dies before attaining the age of [number] years and the trust estate has not previously been exhausted or otherwise terminated by exercise of the powers conferred on the Trustee under this Agreement, upon the death of the Beneficiary, the trust shall terminate, all undistributed net income shall be added to principal, and the entire then remaining principal of the trust estate, which is referred to in this Section as the “Remaining Principal,” shall be disposed of as follows:

a. The Trustee shall distribute such amounts of the Remaining Principal to or for the benefit of my descendants, born or...