HISHAW LAW LLC.

Welcome to Hishaw Law Young Adult Incapacity Plan!

Here are a few tips before you begin:

1.Don’t overthink this! These questions are simply designed to get you thinking about what matters. For just $147, you can get a Young Adult Incapacity Plan prepared and delivered by a highly qualified, licensed attorney. It’s a solid legal foundation that can be updated as life changes.

2.This is designed to be quick and easy! Most people finish it in just 15–20 minutes!

3.You can revisit the site if you need to make changes or updates at any time (just use the username and password you created).

4.Once you’re satisfied with your answers, simply click to submit them. You’ll then be directed to complete payment for your plan.

5. Once completed and paid, our attorney will review them and prepare them for signing.

If you run into any issues or problems, reach out to our team for assistance at 919-663-2471

Registration
Please use your legal name as it appears on your license or government-issue ID

Please use your legal name as it appears on your license or government-issue ID

First Name *

Middle Name

Last Name *

Email *

Password *

Cell *

Young Adult Info
Please provide the name of your college student. You are filling this out for them; their name will be selected as the primary” in the document while you can provide your name as their agent.

Are you a parent filling this out for your college student? *

✓

Yes

✓

No

Student Name

Your Contact Details
Your Contact Details

Name:

Date Of Birth *

Also known as(optional)

Are you married? *

✓

Yes

✓

No

Suffix(optional)

✓

Jr

✓

Sr

✓

II

✓

III

✓

Other

What are your personal pronouns?

✓

he/him

✓

she/her

✓

they/them

Your Address

Full Address: *

Address Line 1 *

Address Line 2

City *

State *

County *

Zip Code *

Is Your mailing address the same as your home address? *

✓

Yes

✓

No

Financial DPOA:
Name someone (agents) you trust to make financial decisions on your behalf in the event you are unable to do so yourself.

Provide the information of one or more individuals who will serve as your agent under the Durable Power of Attorney:

Primary Agent: *

Phone Number *

Address *

Health Care POA
Name someone (agents) to make medical decisions on your behalf in the event that you are unable to make those decisions for yourself

Please provide the information of one or more individuals who will serve as your health care agent:

Do you wish to use the same agents as your Financial Durable POA? *

✓

Yes

✓

No

Primary Agent: *

Phone Number *

Address *

Financial DPOA:
Name someone (agents) you trust to make financial decisions on your behalf in the event you are unable to do so yourself.

Provide the information of one or more individuals who will serve as your agent under the Durable Power of Attorney:

Primary Agent: *

Phone Number *

Email Address *

Alternative Agent * Click the "+" button to add another agent

Phone Number *

Email Address *

HIPAA Agents
Under federal law, the Health Insurance Portability and Accountability Act (HIPAA) prohibits your medical providers from disclosing your medical information to anyone other than you or individuals you have specifically authorized.

Please provide the information of one or more individuals who will serve as your hipaa agent:

Do you wish to use the same agents as your Medical Health Care Power of Attorney? *

✓

Yes

✓

No

Primary Agent : Full Legal Name: * Click the "+" button to add another agent

Phone Number

Address

HIPAA Agents
Under federal law, the Health Insurance Portability and Accountability Act (HIPAA) prohibits your medical providers from disclosing your medical information to anyone other than you or individuals you have specifically authorized.

Please provide the information of one or more individuals who will serve as your hipaa agent:

Do you wish to use the same agents as your Medical Health Care Power of Attorney? *

✓

Yes

✓

No

Primary Agent : Full Legal Name: *

Phone Number

Address

Alternative Agent *

Phone

Address

Alternative Agent * Click the "+" button to add another agent

Phone *

Address *

HIPAA Agents Spouse/Partner
Under federal law, the Health Insurance Portability and Accountability Act (HIPAA) prohibits your medical providers from disclosing your medical information to anyone other than you or individuals you have specifically authorized.

Please provide the information of individuals who will serve as your hipaa agent:

Do you wish to use the same agents as your Medical Health Care Power of Attorney? *

✓

Yes

✓

No

Primary Agent : Full Legal Name: *

Phone Number

Address

Alternative Agent *

Phone

Address

Alternative Agent * Click the "+" button to add another agent

Phone *

Address *

Summary
Summary

If you would like to review your responses, please review your responses on the right hand side on the specific screens. After you click submit, you will be finished and we will email your answer and the office will contact you with the next steps .

Your Progress