Free County, Colorado - Colorado

District Court Denver Probate Court _________________________________ County, Colorado Court Address: _________________________________________________ In the Interests of: COURT USE ONLY Case Number: ___________________

_____________________________________________ Ward/Protected Person

Division______ Courtroom ________

PROVISIONAL LETTERS PURSUANT TO §15-14.5-302, C.R.S.
_____________________________________________ (Name) was appointed or qualified by this Court with an order for provisional appointment on _____________________________ (date) as: Conservator. These are Letters of Conservatorship Guardian. These are Letters of Guardianship for an incapacitated person.

These Provisional Letters are proof of the Guardian's/Conservator's authority to act and shall expire 60 days from issuance, unless extended by order of the Court with the following limitations. The Guardian shall have access to Ward's medical records and information to the same extent that the Ward is entitled. The Guardian shall be deemed to be Ward's personal representative for all purposes relating to Ward's protected health information, as provided in HIPAA, Section 45 CFR 164.502(g)(2). 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 Ward pursuant to §15-14316(4), C.R.S. Other limitations: ______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Date: _____________________________

___________________________________ Probate Registrar/(Deputy)Clerk of Court CERTIFICATION

Certification Stamp

or

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 781

9/08

PROVISIONAL LETTERS PURSUANT TO §15-14.5-302, C.R.S