Power of Attorney for Health Care - Nebraska

Nebraska
Power of Attorney for Health Care
1. I appoint _______________________________________________, whose address is
_____________________________________________________________ and whose
telephone number is ___________________________ as my attorney-in-fact for health
care. I appoint ________________________________________, whose address is
__________________________________________, and whose telephone number is
_________________, as my successor attorney-in-fact for health care. I authorize my
attorney-in-fact appointed by this document to make health care decisions for me when I
am determined to be incapable of making my own health care decisions. I have read the
warning which accompanies this document and understand the consequences of executing
a power of attorney for health care.
2. I direct that my attorney-in-fact comply with the following instructions or limitations:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
3. I direct that my attorney-in-fact comply with the following instructions on life-
sustaining treatme nt: (optional) ___________________ ____________________________
_________________________________________________________________________
_________________________________________________________________________
4. I direct that my attorney-in-fact comply with the following instructions on artificially
administered nutrition and hydration: (optional) __________________________________
_________________________________________________________________________
_________________________________________________________________________
I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I
UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND
DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH
DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF
ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY
ATTORNEY-IN-FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A
PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN
THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY
INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN.
________________________________________
Page 1/3
Free Download

Power of Attorney for Health Care - Nebraska PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 1021 Views | 7 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 916 Views | 3 Downloads
  •  
  •  
  •  
  •  
  •  
9 Page(s) | 3019 Views | 23 Downloads
  •  
  •  
  •  
  •  
  •  
8 Page(s) | 3346 Views | 34 Downloads
  •  
  •  
  •  
  •  
  •  
3 Page(s) | 1770 Views | 5 Downloads