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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 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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