Fillable Printable Power of Attorney for Health Care - Nebraska

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.

________________________________________

(Signature of person making designation/date)

Declaration of Witnesses

We declare that the principal is personally known to us, that the principal signed or

acknowledged his or her signature on this power of attorney for health care in our

presence, and that the principal appears to be of sound mind and not under duress or undue

influence, and that neither of us nor the principal’s attending physician is the person

appointed as attorney in fact by this document.

Witnessed By:

_______________________________ _______________________________

(Signature of Witness/Date) (Printed Name of Witness)

_______________________________ _______________________________

(Signature of Witness/Date) (Printed Name of Witness)

State of Nebraska )

) ss,

County of ___________________________ )

On this _____ day of ______________________ 20 __, before me, ______________

_________________________, a notary public in and for __________________________

County, personally came _______________________________, personally known to be

the identical person whose name is affixed to the above power of attorney for health care

as principal, and I declare that he or she acknowledges the execution of the same to be his

or her voluntary act and deed, and that I am not the attorney-in-fact or successor attorney-

in-fact designated by this power of attorney for health care.

Witness my hand and notarial seal at _______________________ in such county the

day and year last above written.

_______________________________

Notary Public