Nebraska Power Of Attorney For Health Care Form printable pdf download

Nebraska

Power of Attorney for Health Care

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.

I direct that my attorney-in-fact comply with the following instructions or limitations:

_________________________________________________________________________

I direct that my attorney-in-fact comply with the following instructions on life-

sustaining treatment: (optional) _______________________________________________

_________________________________________________________________________

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.

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