162A.860. Power of attorney: Form, NV ST 162A.860
1. DESIGNATIO N OF HEALTH CARE AGENT.
I, , do hereby designate and appoint:
(insert your name)
as my agent to make health care decisions for me as authorized in this document.
(Insert the name and address of the person you wish to designate as your agent to make health care decisions for you. Unless
the person is also your spouse, legal guardian or the person most closely related to you by blood, none of the following may be
designated as your agent: (1) your treating provider of health care; (2) an employee of your treating provider of health care; (3)
an operator of a health care facility; or (4) an employee of an operator of a health care facility.)
2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.
By this docum ent I inte nd t o create a dura ble po wer of att orney by appoi nting t he perso n designat ed above t o m ake health care
decisions for me. This power of attorney shall not be affected by my subsequent incapacity.
3. GENERAL STATEMENT OF AUTHORITY GRANTED.
In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent
named above full power and a uthority: to m ake health care decisions for m e before or a fter my deat h, including co nsent, refusal
of consent or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or
mental condition; to request, review and receive any information, verbal or written, regarding my physical or mental health,
including, without limitation, medical and hospital records; to execute on my behalf any releases or other documents that may
be required to obtain medical care and/or medical and hospital records, EXCEPT any power to enter into any arbitration
agreements or execute any arbitration clauses in connection with admission to any health care facility including any skilled
nursing facility; and subj ect only to the limitations and special provisions, if any, set forth in paragraph 4 or 6.
4. SPECIAL PROV ISI O NS AND LIMITATIO NS.
(Your agent is not permitted to consent to any of the following: commitment to or placement in a mental health treatment
facility, convulsive treatment, psychosurgery, sterilization or abor tion. If there are any other types of treatment or placement
that you do not want your agent’s authority to give consent for or other restrictions you wish to place on his or her agent’s
authority, you should list them in the space below. If you do not write any limitations, your agent will have the broad powers
to make health care decisions on your behalf which are set forth in paragraph 3, except to the extent that there are limits provided
In exercising the authority under this durable power of attorney for health care, the authority of my agent is subject to the
following special provisions and limitations:
I understand that this power of attorney will exist indefinitely from the date I execute this document unless I establish a shorter
time. If I am unabl e t o make health care decisions for myself when this power of attorney expires, the authority I have granted
my agent will continue to exist until the time when I become able to make health care decisions for myself.
I wish to have this power of attorney end on the following date: