Durable Power of Attorney for Health Care Decisions - Nevada

162A.860. Power of attorney: Form, NV ST 162A.860
A. First Alternative Agent
Name:
Address:
Telephone Number:
B. Second Alternative Agent
Name:
Address:
Telephone Number:
8. PRIOR DESIGNATIONS REVOKED.
I revoke any prior durable power of attorney for health care.
9. WAIVER OF CONFLICT OF INTEREST.
If my designated agent is my spouse or is one of my children, then I waive any conflict of interest in carrying out the provisions
of this Durable Power of Attorney for Health Care that said spouse or child may have by reason of the fact that he or she may
be a beneficiary of my estate.
10. CHALLENGES.
If the legality of any prov ision of th is Durable Power of Attorney for Health Care is questioned by my physician, my agent or
a third party, then my agent is authorized to commence an action for declaratory judgment as to the legality of the provision in
question. The cost of any such action is to be paid from my estate. Th is Durable Power of Attorney for Health Care must be
construed and interpreted in accordance with the laws of the State of Nevada.
11. NOMINA TION OF GUARDIA N.
If, after execution of this Durable Power of Attorney for Health Care, incompetency proceedings are initiated either for my
estate or my person, I hereby nominate as my guardian or conservator for consideration by the court my agent herein named,
in the order nam e d.
12. RELEASE OF INFORM A TIO N.
I agree to, authorize and allow full release of information by any government agency, medical provider, business, creditor or
third party who may have in formation pert aining to m y health care, to m y agent named her ein, pursuant t o the Health Insura nce
Portability and Accountability Act of 1996, Public Law 104-191, as amended, and applicable regulations.
(YOU MUST DATE AND SIGN THIS POWER OF ATT ORNE Y)
I sign my name to this Durable Power of Attorney for Health Care on this day of , 20 ,
in , .
(city) (state)

(Signature)
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