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Nebraska Power of Attorney for Health Care Form

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Nebraska Power of Attorney for Health Care Form
Nebraska Power of Attorney for Health Care Form
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 treatment: (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.
________________________________________
Nebraska Power of Attorney for Health Care Form
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