Fill and Sign the Nebraska Power of Attorney for Health Care Statutory Form

Page 1 of 2 Power of Attorney, DC 6:13 PSC, Rev. 08/12 §30-3408 Nebraska Power of Attorney Health Care POWER OF ATTORNEY FOR HEALTH CARE I, _______________________________ (your name) name the following person as my attorney in fact for health care: Name: ________________________________ Address: ___________________________________________ Phone Number: ____________________ SUCCESSOR TO POWER OF A TTORNEY FOR HEALTH CARE If my agent (above) is unwilling or unable to act, I appoint the following person as my successor power of attorney for health care: Name: ________________________________ Address: ___________________________________________ Phone number: ____________________ I understand the consequences of executing a powe r of attorney for health care and I authorize my attorney in fact for health care 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 direct that my attorney in fact for health care comply with the following instructions or limitations: ____________________________ ___________________________________________________________________ I direct that my attorney in fact for health care comply with the following instructions on life- sustaining treatment: ( optional) _____________________________________ _____________________________________________________________________ I direct that my attorney in fact for health care comply with the following instructions on artificially administered nutrition and hydration: ( optional) ______________________________ ______________________________________________________________________ Page 2 of 2 Power of Attorney, DC 6:13 PSC, Rev. 08/12 §30-3408 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 for health care, 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 th e future be confirmed by a second physician. ____________________ _____________ Signature of person making designation Date DECLARATION OF WITNESSES We declare that the individual si gning this power of attorney for health care is personally known to us, has signed or acknowledged his or her signatu re on this power of attorney for health care in our presence, and appears to be of sound mi nd and not under duress or undue influence. Furthermore, neither of us, nor the principal' s attending physician, is the person appointed as attorney in fact for health care by this document. Witnessed By: (Signature of Witness/Date) (Printed Name of Witness) (Signature of Witness/Date) (Printed Name of Witness) OR NOTARY State of Nebraska [County] of This document was acknowledged before me on , (Date) by (Name of Principal) (Seal, if any) Signature of Notary My commission expires: