DURABLE POWER OF ATTORNEY
FOR HEALTH CARE DECISIONS
WARNING TO PERSON EXECUTING THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES 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
ATTORNEY-IN-FACT 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 YOU ALIVE.
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 HEALTH CARE
DECISIONS FOR YOU BY NOTIFYING THAT PERSON OF THE
REVOCATION 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 DECISIONS 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 REVOKES ANY PRIOR DURABLE POWER OF
ATTORNEY FOR HEALTH CARE.
10. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.
1. DESIGNATION OF HEALTH CARE AGENT.
I, ____________________________________ (insert your name) do hereby designate and
appoint:
Name: _____________________________________________________________
Address: _____________________________________________________________
Telephone Number: ________________________________
as my attorney-in-fact 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 attorney-in-fact
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 attorney-in-fact: (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 document I intend to create a durable power of attorney by appointing the person
designated above to make 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 attorney-in-fact named above full power and authority to
make health care decisions for me before, or after my death, including: 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, subject only to the limitations
and special provisions, if any, set forth in paragraph 4 or 6.
INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY
PHYSICAL OR MENTAL HEALTH.
A. General Grant of Power and Authority. Subject to any limitations in this Directive, my
agent has the power and authority to do all of the following: (1) Request, review and
receive any information, verbal or written, regarding my physical or mental health
including, but not limited to, medical and hospital records; (2) Execute on my behalf any
releases or other documents that may be required in order to obtain this information; (3)
Consent to the disclosure of this information; and (4) Consent to the donation of any of
my organs for medical purposes. . (If you want to limit the authority of your agent to
receive and disclose information relating to your health, you must state the limitations in
section 4, “Special Provisions, and Limitations”, below.)
B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my
rights regarding the use and disclosure of my individually identifiable health information
or other medical records. This release authority applies to any information governed by
the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C.
1320d and 45 CFR 160 through 164. I authorize any physician, health care professional,
dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care
provider, any insurance company, and the Medical Information Bureau, Inc. or other
health care clearinghouse that has provided treatment or services to me, or that has paid
for or is seeking payment from me for such services, to give, disclose and release to my
agent, without restriction, all of my individually identifiable health information and
medical records regarding any past, present or future medical or mental health condition,
including all information relating to the diagnosis of HIV/AIDS, sexually transmitted
diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall
supersede any other agreement that I may have made with my health care providers to
restrict access to or disclosure of my individually identifiable health information. The
authority given my agent has no expiration date and shall expire only in the event that I
revoke the authority in writing and deliver it to my health care provider.
4. SPECIAL PROVISIONS AND LIMITATIONS.
(Your attorney-in-fact 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 abortion. If there are any other types of treatment or placement that you
do not want your attorney-in-fact’s authority to give consent for or other restrictions you
wish to place on his or her attorney-in-fact’s authority, you should list them in the space
below. If you do not write any limitations, your attorney-in-fact 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 attorney-in-fact 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 unable to make health care decisions
for myself when this power of attorney expires, the authority I have granted my attorney-
in-fact 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:
___________________________________
6. STATEMENT OF DESIRES.
(With respect to decisions to withhold or withdraw life-sustaining treatment, your
attorney-in-fact 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 attorney-in-fact has the duty to act in your best interests; and, under some
circumstances, a judicial proceeding may be necessary so that a court can determine the
health care decision that is in your best interests. If you wish to 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 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.) [ ]
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 gastro-intestinal tract after all other treatment is withheld. [ ]
5. I do not desire treatment to be provided and/or continued if the burdens of the
treatment outweigh the expected benefits. My attorney-in-fact is to consider the relief of
suffering, the preservation or restoration of functioning, and the quality as well as the
extent of the possible extension of my life. [ ]
(If you wish to change your answer, you may do so by drawing an “X” through the
answer you do not want, and circling the answer you prefer.)
Other or Additional Statements of Desires:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. DESIGNATION OF ALTERNATE ATTORNEY-IN-FACT.
(You are not required to designate any alternative attorney-in-fact but you may do so.
Any alternative attorney-in-fact you designate will be able to make the same health care
decisions as the attorney-in-fact designated in paragraph 1, page 2, in the event that he or
she is unable or unwilling to act as your attorney-in-fact. Also, if the attorney-in-fact
designated in paragraph 1 is your spouse, his or her designation as your attorney-in-fact is
automatically revoked by law if your marriage is dissolved.)
If the person designated in paragraph 1 as my attorney-in-fact is unable to make health
care decisions for me, then I designate the following persons to serve as my attorney-in-
fact to make health care decisions for me as authorized in this document, such persons to
serve in the order listed below:
A. First Alternative Attorney-in-fact
Name: _____________________________________________________________
Address: _____________________________________________________________
Telephone Number: ________________________________
B. Second Alternative Attorney-in-fact
Name: _____________________________________________________________
Address: _____________________________________________________________
Telephone Number: ________________________________
8. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney
for health care.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Durable Power of Attorney for Health care on
________________________________ (date) at ________________________________
(city), ________________________________ (state).
_______________________________
(Signature)
(THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH
CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO
QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO
ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR
(2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.)
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
(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
20 _______ before me, ______________________________________________________
(here insert name of notary public) personally appeared
___________________________________ (here insert name of principal) personally
known to me (or proved to me on the basis of satisfactory evidence) to be the person
whose name is subscribed to this instrument, and acknowledged that 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 SEAL
__________________________________
(Signature of Notary Public)
STATEMENT OF WITNESSES
(You should carefully read and follow this witnessing procedure. This document will not
be valid unless you comply with the witnessing procedure. If you elect to use witnesses
instead of having this document notarized you must use two qualified adult witnesses.
None of the following may be used as a witness: (1) a person you designate as the
attorney-in-fact, (2) a provider of health care, (3) an employee of a provider of health
care, (4) the operator of a health care facility, (5) an employee of an operator of a health
care facility. At least one of the witnesses must make the additional 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 attorney-in-fact 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
community care facility, nor an employee of an operator of a health care facility.
Signature: ___________________________________________________________
Residence Address: ___________________________________________________
Print Name: _________________________________________________________
Date: ___________________________
Signature: ___________________________________________________________
Residence Address: ___________________________________________________
Print Name: _________________________________________________________
Date: ___________________________
(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE
FOLLOWING DECLARATION.)
I declare under penalty of perjury that I am not related to the principal by blood,
marriage, or adoption, and to the best of my knowledge I am not entitled to any part of
the estate of the principal upon the death of the principal under a will now existing or by
operation of law.
Signature: ______________________________________________________
Signature: ______________________________________________________
-----------------------------------------------------------------------------------------------------------
Names: ___________________________Address: ___________________________
Print Name: __________________________________________________________
Date: ___________________________
COPIES: You should retain an executed copy of this document and give one to your
attorney-in-fact. The power of attorney should be available so a copy may be given to
your providers of health care.
DECLARATION OF LIVING WILL
Declaration made this _____ day of _____ (month, year). I, _______, being of sound
mind, willfully and voluntarily make known my desire that my dying shall not be
artificially prolonged under the circumstances set forth below, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a
terminal condition or a permanently unconscious condition by 2 physicians who have
personally examined me, one of whom shall be my attending physician, and the
physicians have determined that my death will occur whether or not life-sustaining
procedures are utilized or that I will remain in a permanently unconscious condition and
where the application of life-sustaining procedures would serve only to artificially
prolong the dying process, I direct that such procedures be withheld or withdrawn, and
that I be permitted to die naturally with only the administration of medication,
sustenance, or the performance of any medical procedure deemed necessary to provide
me with comfort care. I realize that situations could arise in which the only way to allow
me to die would be to discontinue artificial nutrition and hydration. In carrying out any
instruction I have given under this section, I authorize that artificial nutrition and
hydration not be started or, if started, be discontinued. (yes) (no) (Circle your choice and
initial beneath it. If you do not choose "yes," artificial nutrition and hydration will be
provided and will not be removed.)
In the absence of my ability to give directions regarding the use of such life-sustaining
procedures, it is my intention that this declaration shall be honored by my family and
physicians as the final expression of my right to refuse medical or surgical treatment and
accept the consequences of such refusal.
I understand the full import of this declaration, and I am emotionally and mentally
competent to make this declaration.
Signed _____________________________________
State of __________________
_________________ County
We, the following witnesses, being duly sworn each declare to the notary public or justice
of the peace or other official signing below as follows:
1. The declarant signed the instrument as a free and voluntary act for the purposes
expressed, or expressly directed another to sign for him.
2. Each witness signed at the request of the declarant, in his presence, and in the presence
of the other witness.
3. To the best of my knowledge, at the time of the signing the declarant was at least 18
years of age, and was of sane mind and under no constraint or undue influence.
___________________________________ Witness
___________________________________ Witness
The affidavit shall be made before a notary public or justice of the peace or other official
authorized to administer oaths in the place of execution, who shall not also serve as a
witness, and who shall complete and sign a certificate in content and form substantially
as follows:
Sworn to and signed before me by _______, declarant _______ and _______, witnesses
on _______.
__________________________________
Signature
__________________________________
Official Capacity
