Physicians Affidavit

MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITYOF ST. LOUIS In the Matter of No. Respondent AFFIDAVIT IN SUPPORT OF PETITION FOR APPOINTMENT OF GUARDIAN-CONSERVATOR ______________________________________ of lawful age, being duly sworn upon his/her oath, states the following: I am a physician licensed to practice medicine in the State of Missouri. My license to practice medicine is not subject to any restrictions imposed by the Board of Healing Arts of the State of Missouri; I am aware that the information provided herein will be used solely in the course of a judicial proceeding and therefore constitutes an exception to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) under the provisions of 45CFR164.512. I have been the attending physician for _________________________________ since ________, and last examined him/her on_________________________. My diagnosis (es) for _____________________________________________ is/are: Primary Diagnosis:________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Secondary Diagnosis:_____________________________________________________________________ _______________________________________________________________________________________ My diagnosis(es) is/are based upon the following, tests, observations or other findings: _____ _____ _____ _____ American LegalNet, Inc. www.FormsWorkFlow.com _____ _ _____ In my opinion, based upon a reasonable degree of medical certainty, I _________________________ (consider-- do not consider) _____________________________ to be unable by reason of said physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to meet his/her essential requirements for food, clothing, shelter, safety, or medical care such that serious physical injury, illness, or disease is likely to occur. In my opinion, based upon a reasonable degree of medical certainty, I _________________________ (consider--do not consider) ______________________________ to be unable by reason of said physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to manage his/her financial affairs. ___________________________________ AFFIANT Date:_______________ KNOW ALL MEN BY THESE PRESENTS, that I, the undersigned Notary Public, hereby certify that the above-named deponent was first duly sworn by me to make true answers to the foregoing interrogatories and that this affidavit was subscribed to by the deponent in my presence. ___________________________________ NOTARY PUBLIC My Commission Expires: _________________ American LegalNet, Inc. www.FormsWorkFlow.com