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Original Draft Date: January 13, 2003, Last Revision Date: July 2016 SUBJECT:Disclosures of Identified Health InformationHIPAA CITES:45 CFR 164.502(d), 164.514(a)(c)DEPARTMENT:All Departments of Detainee

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To fill out the McDermott Will & Emery form, follow these steps: 1. Obtain a copy of the form, either in physical or digital format. 2. Read the instructions provided with the form carefully to understand the requirements. 3. Gather all the necessary information such as personal details, assets, beneficiaries, and any special instructions. 4. Start by entering your personal information, including your full name, address, and contact details. 5. Proceed to list your assets and their estimated values, such as real estate properties, bank accounts, investments, and personal belongings. 6. Specify the beneficiaries who will inherit your assets after your passing. Include their names, relationship to you, and their contact information. 7. If you have any specific instructions regarding your assets or estate distribution, provide them in the designated section. 8. Carefully review the filled-out form for any mistakes or omissions. 9. Sign the form and date it before submitting it.

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