Structure
In Nebraska, the Medical Power of Attorney form is a crucial legal document that allows individuals to designate a trusted person to make healthcare decisions on their behalf when they are unable to do so themselves. This form ensures that your medical preferences are respected, even if you cannot communicate them directly. It covers a wide range of healthcare decisions, including treatment options, end-of-life care, and the right to access medical records. The appointed agent, often a family member or close friend, must act in accordance with your wishes and best interests. Completing this form requires careful consideration, as it empowers someone else to make significant decisions regarding your health. Understanding the key components of this form, such as the appointment of an agent, the scope of authority, and the necessary signatures, is essential for anyone looking to ensure their medical preferences are honored in times of need.
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Nebraska Medical Power of Attorney
This Medical Power of Attorney is a legal form that grants an individual the authority to make health care decisions on your behalf, should you become unable to do so. It is governed by the laws of the State of Nebraska. Completing this form ensures that your medical care preferences are known and considered when you can't communicate them yourself.
Please complete the following information to create your Medical Power of Attorney:
Section 1: Principal Information
Full Name of Principal (Person Granting the Power): ___________________________________________________
Date of Birth: ___________________
Primary Address: _______________________________________________
City: ______________________
State: NE
Zip Code: _______________
Section 2: Agent Information
Full Name of Agent (Person Granted the Power): _____________________________________________________
Relationship to Principal: ______________________________________
Primary Address: _______________________________________________
City: ______________________
State: _____________________
Zip Code: _______________
Alternate Phone Number: ___________________________________
Section 3: Powers Granted
This document authorizes the Agent to make all forms of health care decisions on the Principal's behalf that the Principal could make, including decisions about the selection of health care providers, hospital stays, treatment plans, and receiving access to medical records.
Section 4: Special Instructions
If there are any specific wishes, limitations, or exceptions to the powers granted, list them here: ____________________________________________________________________________________________________
Section 5: Duration of Power of Attorney
This Medical Power of Attorney becomes effective immediately upon signing and remains effective indefinitely unless the Principal specifies an expiration date or revokes it in writing.
Expiration Date (if applicable): ____________________________
Section 6: Signatures
The Principal and Agent must sign and date the document in the presence of two witnesses or a notary public. By signing, all parties agree to the terms set forth in this Medical Power of Attorney.
Principal's Signature: __________________________ Date: ____________
Agent's Signature: _____________________________ Date: ____________
Witness #1 Signature: __________________________ Date: ____________
Witness #2 Signature: __________________________ Date: ____________
Notarization (if applicable):
This document was notarized on __________________ (date) in the State of Nebraska.
Section 7: Declarations
Notice to Principal: You have the right to revoke this document at any time by providing written notice to your designated agent.
Notice to Agent: You are not obligated to act as an Agent unless you choose to accept this responsibility. If you accept, you are obligated to act in accordance with the Principal's desires as stated in this document or otherwise communicated to you.
Section 8: Acknowledgment of Agent
I, _________________________ (Agent), acknowledge that I have been appointed as an agent by the Principal named in this document. I understand my responsibilities and agree to act according to the Principal’s wishes to the best of my ability.
Agent's Signature: _____________________________ Date: ____________
Document Features
| Fact Name | Description |
|---|---|
| Purpose | The Nebraska Medical Power of Attorney form allows an individual to appoint someone to make medical decisions on their behalf if they become unable to do so. |
| Governing Law | This form is governed by the Nebraska Revised Statutes, specifically Sections 30-3401 to 30-3435. |
| Eligibility | Any adult resident of Nebraska can create a Medical Power of Attorney, provided they are of sound mind. |
| Agent Selection | The individual creating the form can choose any competent adult as their agent, including family members or friends. |
| Revocation | The Medical Power of Attorney can be revoked at any time by the principal, as long as they are mentally competent to do so. |
| Signature Requirements | The form must be signed by the principal and witnessed by two individuals or notarized to be valid. |
| Effective Date | The authority granted through the Medical Power of Attorney becomes effective only when the principal is declared incapacitated by a physician. |
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