Fillable Printable Durable Power of Attorney for Health Care Decisions - Nevada

Durable Power of Attorney for Health Care Decisions - Nevada

162A.860. Power of attorney: Form, NV ST 162A.860

DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS

WARNING TO PERSON EXECUTING THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. IT C REATES A DURABLE POWER OF ATTORNEY FOR HEALTH

CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT THE POWER TO MAKE HEALTH

CARE DECISIONS FOR YOU. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR

DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR

YOU MAY INCLUDE CONSENT, REFUSAL OF CONSENT OR WITHDRAWAL OF CONSENT TO ANY CARE,

TREATMENT, SERVICE OR PROCEDURE TO MAINTAIN, DIAGNOSE OR TREAT A PHYSICAL OR MENTAL

CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU

DO NOT DESIRE.

2. THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO ACT CONSISTENT WITH YOUR

DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE

UNKNOWN, TO ACT IN YOUR BEST INTERESTS.

3. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THE POWER OF THE PERSON YOU

DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE THE POWER TO CONSENT TO

YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YO U A LIV E.

4. UNLESS YOU SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THIS POWER WILL EXIST INDEFINITELY

FROM THE DATE YOU EXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE

DECISIONS FOR YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU BECOME

ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.

5. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH

CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE

PARTICULAR DECISION. IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION,

AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED IF YOU OBJECT.

6. YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON DESIGNATED IN THIS DOCUMENT

TO MAKE HEALT H CARE DECISIONS FOR YO U BY NOTIFYING THA T PERSON OF THE REVOC ATION ORALLY

OR IN WRITING.

7. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS

DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN,

HOSPITAL OR OTHER PROVIDER OF HEALTH CARE ORALLY OR IN WRITING.

8. THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISION S FOR YOU HAS THE

RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU

LIMIT THIS RIGHT IN THIS DOCUMENT.

9. THIS DOCUMENT REV OKE S AN Y PRIOR DURAB LE PO WER OF ATTORNEY FOR HEALTH C ARE.

10. IF THERE IS ANYT HI N G IN TH IS D OCUM ENT THAT YO U D O NOT UN DERSTAND, YOU S H OUL D ASK A

LAWYER TO EXPLAIN IT TO YOU.

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)

Name:

Address:

Telephone Number:

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

by law.)

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:

5. DURATION.

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.

(IF APPLICABLE)

I wish to have this power of attorney end on the following date:

162A.860. Power of attorney: Form, NV ST 162A.860

6. STATEMENT OF DESIRES.

(With respect to decisions to withhold or withdraw life-su staining treatment, your agent must make health care decisions that

are consistent with your known desires. You can, but are not required to, indicate your desires below. If your desires are

unknown, your agent has the duty to act in your best interests; and, under some circumstances, a judicial proceeding may be

necessary so that a court ca n determine the health care decision that is in your best interests. If you wish t o indicate your desires,

you may INITIAL the statement or statements that reflect your desires and/or write your own statements in the space below.)

(If the statement reflects your desires, initial the box next to the statement.)

1. I desire that my life be prolonged to the greatest extent possible,

without regard to my condition, the chances I have for recovery or long-

term survival, or the cost of the procedures.

[ ]

2. If I am in a coma which my doctors have reasonably concluded is

irreversible, I desire that life-sustaining or prolonging treatments not be

used. (Also should utilize provisions of NRS 449.535 to 449.690,

inclusive, if this subparagraph is initialed.)

[ ]

3. If I have an incurable or terminal condition or illness and no

reasonable hope of long-term recovery or survival, I desire that lif e-

sustaining or prolonging treatments not be used. (Also should utilize

provisions of NRS 449.535 to 449.690, inclusive, if this subparagraph is

initialed.)

[ ]

4. Withholding or withdrawal of artificial nutrition and hydration may

result in death by starvation or dehydration. I want to receive or continue

receiving artificial nutrition and hydration by way of the gastrointestinal

tract after all other treatment is withheld.

[ ]

5. I do not desire treatment to be provided and/or conti n ued if the

burdens of the treatment outweigh the expected benefits. My agent is to

consider the relief of suffering, the preservation or restorat ion of

functioning, and the quality as well as the extent of the possible

extension of my life.

[ ]

(If you wish to change your answ er, you may do so by drawing an “X” through the answer you do no t want, and circling the

answer you prefer.)

Other or Additional Statements of Desires:

7. DESIGNAT IO N OF ALT ERNATE AGE NT.

(You are not required to designate any alternative agent but you may do so. Any alternative agent you designate will be able to

make the same health care decisions as the agent designated in paragraph 1, page 2, in the event that he or she is unable or

unwilling to act as your agent. Also, if the agent designated in paragraph 1 is your spouse, his or her designation as your agent

is automatically revoked by law if your marriage is dissolved.)

If the person designated in paragraph 1 as my agent is unable to m ake health care decisions for me, then I designate the following

persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the

order listed below:

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)

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(Signature)

162A.860. Power of attorney: Form, NV ST 162A.860

CERTIFICATE OF ACKNOWLEDG MENT OF N OTAR Y PUB L IC

(You may use acknowledgment before a notary public instead of the statement of witnesses.)

State of Nevada )

)ss

County of )



On this day of , in the year , before me,

(here insert name of notary public) personally appeared (here

insert name of principal) pers onally know n to me (or pr oved to me on t he basis of satisfactory evidence) to be the person whose

name is subscribed to this instrument, and acknowledged th at he or she executed it. I declare under penalty of perjury that the

person whose name is ascribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence.





(Notary Public)

162A.860. Power of attorney: Form, NV ST 162A.860

STATEMENT OF WITNESSES

(You should carefully read and follow th is witnessin g proced ure. This docu ment will no t be valid un less you co mply with th e

witnessing procedure. If you elect to use wit nesses instead of having t his doc ument nota rized, yo u must use tw o qualifi ed adult

witnesses. None of the following may be used as a witness: (1) a person you designate as the agent; (2) a provider of health

care; (3) an employee of a provider of health care; (4) the operator of a h ealth care facility; or (5) an employee of an operator

of a health care facility. At least one of the witnesses must make the ad ditional declaration set out following the place where

the witnesses sign.)

I declare under penalty of perjury that the principal is personally known to me, that the principal signed or

acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no

duress, fraud or undue influence, that I am not the person appointed as agent by this document and that I am not a provider of

health care, an employee of a provider of health care, the operator of a health care facility or an emplo yee of an operator of a

health care facility.

Signature: _______________________________________

Print Name: ______________________________________

Date: ________ ___________________________________

Residential Address: _______________________________

________________________________________________

Signature: _______________________________________

Print Name: ______________________________________

Date: ________ ___________________________________

Residential Address: _______________________________

________________________________________________

(AT LEAST ONE OF THE ABOVE WIT N E SSES MUS T ALSO SI G N THE FO LLO WI NG DECL ARATION.)

I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the

best of my knowledge, I am not entitled to any part of the estate of the prin cipal upon the death of the princip al under a will

now existin g or by operation of la w.

Signature:

Names: _______________ ___ ___ ___ ______ ___ ___ ___ __

Print Name: ______________________________________

Date: ________ ___________________________________

Address: __________________________ ______________

________________________________________________

COPIES: You should retain an executed cop y of th is document and g ive on e to you r ag en t. The power of attorn ey sh ou ld be

available so a copy may be given to your providers of health care.