Authorization for Internet Access*
(In compliance with HIPAA rules and regulations)
In order to make my health information available to
Medical personnel in the fastest way possible, I
authorize MyLifeCard International, Inc. to transmit
this information by means of the Internet. Since
MyLifeCard International, Inc. agrees to use its best
efforts to assure that there will be no unauthorized
access, I agree not to hold MyLifeCard International,
Inc. responsible for any violation by any unauthorized
While I may revoke this permission for Internet Access
I cannot hold MyLifeCard International, Inc.
responsible for any transmission sent prior to
MyLifeCard International, Inc.ís receiving such notice.
MyLifeCard International, Inc. disavows any liability
for incorrect information supplied by any member and I
hold harmless MyLifeCard International, Inc. for any
damages arising there from.
I have read and agree to these terms.
Advance Medical Directive (Optional)
Following are three general statements about
withholding and removal of life-sustaining treatment.
After carefully reading all three of these statements,
if you agree with one of them you may select that
option. IF YOU DO NOT CHOOSE ANY ONE OF THE FOLLOWING
STATEMENTS, ALL LIFE-SUSTAINING DECISIONS WILL BE MADE
BY YOUR PHYSICIAN, FAMILY OR DESIGNATED AGENT.
Option 1: I want efforts to prolong my life and
life-sustaining treatment to be provided even if I am
in an irreversible coma or persistent vegetative state.
Option 2: I want efforts to prolong my life and
life-sustaining treatment to be provided unless I am in
a coma or persistent vegetative state, which my doctor
reasonably believes to be irreversible. Once my doctor
has concluded that I will remain unconscious for the
rest of my life, I do not want life-sustaining
treatment to be provided or continued.
Option 3: I do not want efforts to prolong my
life and do not want life-sustaining treatment to be
provided or continued:  if I am in an irreversible
coma or persistent vegetative state; or  if I am
terminally ill and the application of life-sustaining
procedures would serve only to artificially delay the
moment of death; or  under any other circumstances
where the burdens of the treatment outweigh the
expected benefit. I want my agent to consider the
relief of suffering and the quality, as well as the
extent of the possible extension of my life in making
decisions concerning life-sustaining treatment.