JDF 781 SC R9 / 1 8 PROVISIONAL LETTERS PUR SU ANT TO 24715 - 14.5 - 302, C.R.S District Court Denver Probate Court County, Colorado Court Address: In the Interest of: Ward/Protected Person COURT USE ONLY Case Number: Division Courtroom PROVISIONAL LETTERS PURSUANT TO 247 15 - 14.5 - 30 2 , C.R.S. ( n ame) was appointed or qualified by this c ourt with an order for provisional appointment on (date) as: Conservator. These are Letters of Conservatorship . Guardian. These are Letters of Guardianship for an incapacitated pers on. These Provisional Letters are proof of the g / c will expire 60 days from issuance, unless extended by order of the c ourt with the following limitations : The g uardian must have access to w medical records and information to the same extent that the w ard is entitled. The g uardian must be deemed to be w personal representative for all purposes relating to w protected health information, as provided in HIPAA, s ection 45 CFR 164.502(g)(2). The g uar dian 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 w ard pursuant to 247 15 - 14 - 316(4), C.R.S. Other limitations: 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 American LegalNet, Inc. www.FormsWorkFlow.com