Free PROBATE COURT, CITY AND COUNTY OF DENVER, COLORADO - Colorado

District Court Denver Probate Court _________________________________ County, Colorado Court Address: ___________________________________________ In the Interest of: COURT USE ONLY __________________________________________ Case Number:____________________

Respondent/Ward

Division ______ Courtroom _________

LETTERS OF GUARDIANSHIP ­ ADULT
(name _____________ (date) as: Guardian pursuant to §15-14-311, C.R.S. Emergency Guardian pursuant to §15-14-312(1), C.R.S. These letters shall expire on _______________ (a date not to exceed 60 days from the date of appointment). The Guardian's powers are specified in the Order. Temporary Substitute Guardian pursuant to §15-14-313, C.R.S. These letters shall expire on ________________ (a date not to exceed six months from the date of appointment). The Guardian's powers are specified in the previous order of appointment. The Guardian shall have access to Respondent's/Ward's medical records and information to the same extent that the Respondent/Ward is entitled. The Guardian shall be deemed to be Respondent's/Ward's personal representative for all purposes relating to Respondent's/Ward's protected health information, as provided in HIPAA, Section 45 CFR 164.502(g)(2). These Letters of Guardianship are proof of the Guardian's full authority to act, except for the following restrictions: The Guardian does not have the authority to obtain hospital or institutional care and treatment for mental illness, developmental disability or alcoholism against the will of the Respondent/Ward pursuant to §15-14-316(4), C.R.S. The Respondent/Ward's place of residence shall not be changed from the State of Colorado without an order of the Court pursuant to §15-14-315(1)(b), C.R.S. Other limitations: of Guardian) was appointed by Court Order on

Date: _____________________________

___________________________________ Probate Registrar/(Deputy)Clerk of Court CERTIFICATION

Certified to be a true copy of the original in my custody and to be in full force and effect as of _______________. Date ____________________________________ Probate Registrar/(Deputy)Clerk of Court

JDF 849 R4/09

LETTERS OF GUARDIANSHIP - ADULT