Nevada Advance Directive Form

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A Nevada advance directive is a document that allows a person to create a power of attorney for health care and declare a living will. The document lets an agent be designated to make health care decisions on behalf of someone else and to outline their preferred treatment options. An advance directive must be signed with at least two (2) witnesses or a notary public. After completing, it may only be used when the patient becomes incapacitated or not able to make clear decisions for themselves.

Advance Directive Includes

Table of Contents

Laws

Statutes

Signing Requirements (NRS 162A.790, NRS 449A.439) – Two (2) Witnesses.

State Definition (NRS 449A.703) – “Advance directive” means an advance directive for health care. The term includes:

  1. A declaration governing the withholding or withdrawal of life-sustaining treatment as set forth in NRS 449A.400 to 449A.481, inclusive;
  2. A durable power of attorney for health care as set forth in NRS 162A.700 to 162A.870, inclusive;
  3. An advance directive for psychiatric care as set forth in NRS 449A.600 to 449A.645, inclusive;
  4. A do-not-resuscitate order as defined in NRS 450B.420; and
  5. A Provider Order for Life-Sustaining Treatment form as defined in NRS 449A.542.

Versions (3)


AARP

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Nevada Center for Ethics and Policy

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Spanish (Español) Version

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Registry

To register an advance directive for free an individual can send a signed copy along with the attached Registration Agreement (Form SPLB-0001) to the following:

  • Mailing Address: Nevada Lockbox, c/o Nevada Secretary of State, 2250 Las Vegas Blvd. North, Suite 400 North Las Vegas, NV 89030
  • Fax Number: (775) 684-7177

After approximately ten (10) business days, a wallet card will be sent to the declarant with instructions on how to access the document. If for any reason a change is needed to be made to the directive, the declarant can file the Authorization to Change (Form SPLB-0002) in the same manner as above.

How to Write

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Step 1 – Obtain The Nevada Advance Directive From This Site

The Nevada Advance Directive package is a downloadable item using the “Adobe PDF” link presented on this page or the “PDF” button displayed. Both will grant immediate access to this template.

Step 2 – Name Yourself As The Nevada Principal

The Nevada Advance Directive will seek to clearly identify the person issuing it as an appointment of an Attorney-in-Fact over the Principal’s health care decisions in the first article. Find the first available blank line after the section heading “1. Designation Of Health Care Agent.” Record your full name as the Nevada Principal (or future Patient granting medical authority) on this line. 

Step 3 – Produce The Full Name Of Your Nevada Attorney-in-Fact

The presentation of your Health Care Attorney-in-Fact or Nevada Health Care Agent (these terms are interchangeable in this document) must be made immediately after the words “Do Hereby Designate And Appoint.” The “Name” line immediately underneath this phrase expects the full name of the person who carries your approval to discuss and decide your medical issues with Nevada Physicians when you are unconscious or incommunicative for an extended period of time.

Step 4 – Submit The Nevada Attorney-in-Fact’s Address

A key point in someone’s identification, especially a state issued ID such as a driver’s license, is the residential address it displays. Make sure the full residential address of the Nevada Attorney-in-Fact over health care is presented on the next line down (labeled with the word “Address”).

 

Step 5 – Dispense The Telephone Numbers Maintained By The Nevada Attorney-in-Fact

In addition to the full name and residential address of the Nevada Attorney-in-Fact or Health Care Agent, his or her “Phone” number (cellular or home) and “Work” number with any applicable extension, should be recorded. Use the appropriately formatted blank lines that follow to deliver this information to this section. 

 

Step 6 – Include Any Necessary Provisions Regarding The Attorney-in-Fact’s Medical Powers

Read through the remainder of the first article and articles “2. Creation Of Durable Power Of Attorney For health Care” through “4. Special Provisions and Limitations.” While this appointment will grant the same access to your medical records and the same decision making powers with Nevada Physicians to your Health Care Agent, you may wish to make sure that regardless of what the Attorney-in-Fact states, you may wish to make sure certain decisions that you make are honored and fully explained. Utilize the blank lines in “4. Special Provisions And Limitations” to issue direct instructions regarding your preferences for medical scenarios that may be difficult for your Nevada Health Care Agent to decide upon. You may also limit his or her power by putting certain decisions in the hands of the Nevada Physicians in attendance. The provisions you supply here will supersede all other directives so long as they are legally accepted in the State of Nevada. 

 

Step 7 – Optionally Assign A Termination Date

If you have determined that the appointment of your Attorney-in-Fact should be limited by its automatic termination, then locate article “5. Duration.” the two blank lines that follow the words “…Durable Power Of Attorney For Health Care End On” The first of these lines should be used to record the month and two-digit calendar day of the date when you wish this appointment to terminate and the line after the number “20” to document the final two digits of the calendar year for this termination.

 

Step 8 – Engage A Discussion With Your Statement Of Desires

The next section that requires attention is Article “6. Statement Of Desires.” This area presents a list of statements accompanied by a box in the left margin. Every box that bears your initials as the Principal issuing this paperwork will be assumed by Reviewers to be an authorized statement made by you directly to your attending Nevada Medical Staff and Health Care Agent. 

 

Step 9 – Report If You Wish To Receive Full Treatment

Statement (1) beginning with the words “I Desire That My Life…” will declare that you wish to have your life prolonged for as long as possible. Initial the check box to the left of the number 1. If not, then leave this checkbox blank.

Step 10 – Document If Nevada Doctors Should Maintain Your Health In A Coma

Statement (2) in “6. Statement Of Desires” makes use of NRS 449.535 to 449.690 to engage the Principal Patient’s right to die naturally rather than be subjected to life-prolonging treatment when you are in an irreversible coma. Initial this statement to inform Nevada Medical Staff that you withdraw consent to all life support procedures when faced with a permanent coma. 

 

Step 11 – Indicate If You Wish Your Life Prolonged When Terminally III

The third statement “(3) If I Have An Incurable Or Terminal Condition Or Illness And No Reasonable Hope Of Long-Term Recovery…” will allow you as the Principal to inform all Parties charged with your medical care that if you refuse to consent to life-prolonging procedures. Initial this statement to apply it to your directives.

 

Step 12 – Show Your Desire To Have Your Nutrition And Fluid Level Maintained

You may convey your intent to withhold or withdraw consent to receiving artificial nutrition or artificial hydration when you cannot feed or hydrated yourself and are in a coma, a terminal condition, or both by initialing the box accompanying Statement (4). 

 

Step 13 – Demonstrate Your Quality Of Life Versus Longevity Statement

If you prefer that your life not be prolonged artificially when the only treatment for your condition will be overly burdensome, not allow you a quality of life explained to your Agent, and outweigh its benefits, then initial statement (5). 

 

Step 14 – Deliver Your Memorial Service Directives

At the end of the list of statements you have reviewed, a section titled “My Memorial Service” supplies several blank lines that will allow you to define any specific requests you wish fulfilled during your memorial. This can include a list of songs, readings of poetry, or specific mentions. You may leave this section blank if you do not have any such requests. 

 

Step 15 – Attach Additional Directives As Needed

If you have additional requests such as making anatomical gifts, then use the lines in “Add Other Wishes here” to document them. You may be as specific or as general as you like so long as your report accurately describes your wishes. 

Step 16 – Register An Additional Party As An Alternate Attorney-in-Fact

The next article will seek to aid you in setting a precautionary measure should your Nevada Attorney-in-Fact over health care fail to live up to his or her role. He or she may not be available at crucial times, may have had his or her powers revoked, may be ineligible or cannot otherwise effectively act when you have been rendered incapacitated. Review the passages displayed in “7. Designation Of Alternate Attorney-in-Fact.” Here, a specific Party of your choosing should be named as a successor to the Nevada Attorney-in-Fact should he or she no longer be effective (i.e., the original Attorney-in-Fact was the Principal’s Spouse before they divorced). The Nevada Alternate Attorney-in-Fact will not have the ability to wield the Principal’s authority unless the Nevada Health Care Agent cannot or will not represent the Principal 

 

Step 17 – Attach The Alternative Attorney-in-Fact’s Designation

The process of assigning a reserve to act as the First Alternate Nevada Health Care Agent will be handled in the first item of this section “A. First Alternative Attorney-in-Fact” and will be a similar process as that of naming the original Nevada Health Care Attorney-in-Fact. Locate the first labeled empty line in this area then supply the “Name” of the person you wish approached for your medical preferences and can respond with principal authority to Nevada Health Care Professionals should your Nevada Attorney-in-Fact fail.  In addition to naming your First Alternative Attorney-in-Fact, record his or her full “Address” on the line directly underneath.  The telephone numbers where your First Alternative Attorney-in-Fact can be reliably reached should be delivered to the final part of “A. First Alternative Attorney-in-Fact” on the line labeled “Phone” and the line labeled “Work.” Notice that if an extension is needed to reach the First Alternative Attorney-in-Fact then it should be supplied on the “Ext” line.  Of course, there will be instances when both the Nevada Health Care Attorney-in-Fact and First Alternative Attorney-in-Fact cannot fulfill the role of your Nevada Health Care Representative before your Physician. Item “B. Second Alternative Attorney-in-Fact” enables you to handle such a situation now. Utilize the first line, labeled “Name,” to present the identity of the person who carries your approval to define your treatment preferences to Nevada Medical Personnel. Continue one line down then furnish the residential “Address” where the Second Alternative Attorney-in-Fact can be found and can be observed on his or her government-issued ID.  Complete the process of naming your Second Alternative Attorney-in-Fact by recording his or her cellular or home “Phone” number and “Work” number.  

 

Step 18 – Execute This Paperwork With A Dated Signature That Is Witnessed Or Notarized

This document can only act as a legitimate representation of your intent when it is signed on a reported date. The empty line labeled “Date” in the last statement made by this document (see page six) requests that the “Date” when the Nevada Principal signs this appointment is generated as a month and two-digit calendar day then the two-digit calendar year. Use the line labeled as “City And State” to document the location where this paperwork is signed by the Nevada Principal. The Nevada Principal has now named his or her appointment to the role of Attorney-in-Fact over Health Care, two substitute or successors, and provided medical instructions, treatment preferences, or limitations upon what the Attorney-in-Fact can do or decide on in his or her name and how Nevada Medical Staff should respond in certain situations. He or she should review this information then, when satisfied with its presentation, sign his or her full name to the “Signature” line presented.  In addition to signing his or her name, the Nevada Principal should provide a clear presentation of his or her signature by printing his or her name on the “Name” line.  Once the Nevada Principal has completed the signing, the next line shall request the home address where he or she lives. Document this information accordingly.  The two formatted areas that follow are ready to accept the telephone number of the Principal on the “Phone” line, then if available, his or her telephone number at work should be presented.  Finally, this signature area expects that the issuing Nevada Principal’s “Social Security Number” be produced to conclusively identify him or her. 

 

Step 19 – Relinquish This Document To The Nevada Notary Public If Needed

Section “10 Certificate Of Acknowledgment Of Notary Public” can only be completed by a Nevada Notary Public and only upon the completion of the Nevada Principal’s signature area above. Therefore, if you have elected to use a Nevada Notary Public to authenticate the signing, he or she must now take the document then subject it to the notarization process. Review his or her work upon its return. 

 

Step 20 – Anyone Acting As A Witness Must Sign This Document

If you have opted to verify the Nevada Principal’s signature area as properly completed through the testimony of two qualifying Witnesses, then each one must read  “11. State Of Witnesses” A qualifying Witness in this case will be one who is not the Principal’s Attorney-in-Fact, the Nevada Principal’s Health Care Provider, an Employee/Owner/Operator of a Health Care Facility responsible for the Principal’s care and can agree to the declaration statement made in this section. Upon agreement, one of the Witnesses must sign the first available “Signature” line. After proving his or her agreement with the statement above, the Signature Witness must print his or her name on the next line down. The home address of the Witness must be provided for display on the blank line labeled “Residence Address.”After the signature and identification process of the Witness, he or she must dispense the “Date” when these items were produced across the blank lines after the word “Date.”The second “Signature” line must be signed by the other Witness in attendance.
Once the second Witness is complete, this Party must complete the “Print Name” line with his or her own printed name, document his or her home address on the “Residence Address” line, then “Date” his signature with the current calendar month, day, and year across the final two spaces. 

 

Step 21 – At Least One Signature Witness Must Satisfy Specific Criteria

At least one of the Signature Witnesses must be able to agree then complete Article “12. Declaration Of Witness” by attesting to not being “…Related To the Principal By Blood, Marriage, Or Adoption.” and is unaware of gaining any tangible or intangible property upon the Nevada Principal’s death. Both Witnesses should review these criteria in “12. Declaration Of Witness.  The Witness who meets the “12. Declaration Of Witness” criteria must tend the first line under its statement with his or her “Signature.”   In addition to signing the “Declaration Of Witness,” he or she must supply the “Print Name” line with the printed presentation of his or her name.   The “Residence Address” line in this section seeks a record of the Declaring Witness’s home address. Once done, the current “Date” should be recorded by the Declaring Witness as a description of when he or she provided this statement. If both Witnesses meet the qualifications of this section then the second Witness must also sign his or her name, print his or her name, record the residential address where he or she lives, and document the signature date beginning with the second “Signature” line presented in “Declaration Of Witness” and concluding with the formatted “Date” line at the end of his or her signature area. 

 

Step 22 – Review The Nevada Living Will

The next portion of the Nevada Advance Directive is titled “Declaration/Living Will.” This makes use of NRS 449.535 To 449.690 of Nevada Law to aid the Declarant in denying Nevada Health Care Professionals authorization to prolong the Declarant’s life when treatment will not result in a cure, a recovery enabling a reasonable quality of life, and will only stave off death while it is in place. The exception to denying this treatment will be when the concerned procedure or medication plan will alleviate pain (significantly) and provide comfort. As the Nevada Declarant review the paragraphs below the page title “Declaration/Living Will” before continuing. 

 

Step 23 – Establish Your Intent To Engage A Living Will Declaration

If you have reviewed the declaration made and wish to issue include the second paragraph as a formal statement to Nevada Medical Staff requesting that your nutrition and hydration levels are maintained even when this will only prolong your death and even if food and water must be delivered through a tube or intravenously, then initial the box to the left of the words “Withholding Or Withdrawal Of Artificial Nutrition And Hydration…” 

 

Step 24 – Present The Formal Signature Date Of The Nevada Declarant

Issue this declaration to Nevada Medical Personnel through the signature process this document requires. Begin by reporting the calendar day, the month, and the last two digits of the year when the Nevada Declarant signs this document on the blank lines presented after the words “Signed This…” 

 

Step 25 – Display The Declarant’s Signature

The “Signature” line requires the Nevada Declarant to sign his or her name on it to affect his or her declaration.  After the signing, the Nevada Declarant must furnish the residential “Address” of his or her home on the next line then give this document one of the two Witnesses who have observed the completion of the Nevada Declarant’s “Signature” line. 

 

Step 26 – Obtain The Witness Testimonial Signature

The bold statement “The Declarant Voluntarily Signed This Document In My Presence” must be followed by the Witness’s testifying signatures. The first line holding the label “Witness” must be signed by the first Witness to tend to it while the “Address” line below it should be used as a presentation area for his or her home address.  The next Witness should sign the second “Witness” line then supply his or her “Address” (of residence) to the line below it.

 

Step 27 – If Desired Use The Letter To Loved Ones Work Sheet

The next section of this package is not a form that may be considered a legal issue from the Nevada Declarant. It is a template for a letter to the Nevada Declarant’s loved ones as a confirmation of his or her wishes and may be dispensed to those who may not necessarily know the Principal’s wishes as well as his or her Attorney-in-Fact or may be used to help the Principal gather his or her own thoughts to address the Nevada Power of Attorney For Health Care, the Nevada Living Will, and the Nevada POLST that make up the legal documents of this package and are based on NRS 449.535 to 449.690 of Nevada Law. Be advised that the Recipient of this letter is not obligated to accept its authenticity even if it is signed. If you wish to tend to this letter then initial the checkboxes next to each item that defines how you feel after the words “Therefore, I hereby Request As Follows.” Any item not initialed should be considered excluded from your beliefs or desires. In the example below, the Nevada Principal indicates he or she wishes medical treatment geared toward keeping him or her as pain-free as possible. There will also be several sets of blank lines where you can document personal matters. For instance, you can discuss how you wish to be remembered such as in the example below. While this worksheet or form letter will not be considered a legal document that Recipients will be obligated to accept as true, the act of dating and signing it as the Nevada Principal will, in most cases carry quite a bit of weight when it is reviewed by loved ones. Thus, locate the “Date This…” statement at the conclusion of this section (found on page thirteen of the packet) then report the calendar date of signature across the three lines that follow. The “Signature” of the Nevada Declarant must now be presented (on the same date as above). He or she should sign the “Signature” line or if unable to hold a pen correctly place an “X” or qualifying mark (i.e., initials) on this line. The Nevada Declarant’s full printed name must be displayed after the words “Print Name.” 

 

Step 28 – Attend To The Nevada POLST

The final template the Nevada Declarant can issue must be completed with the aid and approval of the Nevada Physician in charge of the Declarant’s care. The “Nevada POLST (Physician Order For Life-Sustaining Treatment)” must begin with an entry of the Nevada Declarant’s last name, first name, and middle initial in the first text box just below the label “Last Name/First/Middle Initial” 

 

Step 29 – Continue Defining The Nevada POLST Declarant’s Identity

The second row of boxes seeks some additional descriptions to the Nevada Declarant identity. The “Date Of Birth” text box seeks the Nevada Declaration birthday as a two-digit calendar day. the two-digit calendar month, and the last two digits of your birth year. Adjacent to this, the second textbox has been formatted to receive the final four digits of the Nevada Declarant’s social security number reported directly under the label “Last 4 SSN” while the final box requires the Nevada Declarant’s “Gender” documented by circling “M” for male and “F” for female. 

 

Step 30 – Indicate The Nevada Declarant’s Cardiopulmonary Arrest Response Preferences

The first topic of this form is found to the right of the title “Section A CPR” and seeks the Nevada Declarant’s preferred response to being found with no pulse and unable to breathe. Normally, Nevada Medical Responders will immediately attempt to revive or resuscitate you mechanically. If you approve of such a response, then mark the box labeled “Attempt Resuscitation” otherwise you must select the second checkbox to indicate that you wish to be allowed a natural death and CPR should not be associated. Notice in the example below that the Nevada Declarant has selected “Allow Natural Death (Do Not Attempt Resuscitation).” Since an EMS is present to verify this choice then he or she should record the “EMS-DNR #” 

 

Step 31 – Solidify The Nevada Declarant’s Preferred Medical Intervention When Suffering

The Nevada Declarant has the right to define how “Medical Interventions” may be conducted or even if they should be conducted when Nevada Medical Personnel find him or her experiencing a severe medical event that does not involve cardiac arrest. To this end review the first item in “Section B Interventions.” If the Nevada Declarant only approves of medical intervention to keep him or her comfortable and wishes to avoid any treatments or hospitalization that includes treatment goals that do not promote comfort or alleviate pain, then select the checkbox labeled “Comfort Measures Only.”  If there are any additional instructions the Nevada Declarant wishes included, these should be reported on the blank line labeled “Other Instructions.”  The second item on this section, labeled “2. Limited Medical Interventions. Comfort Measures Always Provided” will a few topics requiring definition from the Nevada Declarant on what would be an appropriate medical intervention. The first topic is titled “A. Life-Sustaining Antibiotics” and requires that one of its three checkboxes be selected to indicate what level of antibiotic intervention the Nevada Declarant will tolerate. If he or she does not accept the use of any antibiotics, then mark the checkbox labeled “No Antibiotics. Use Other Measures To Relieve Symptoms” If the Nevada Declarant will accept antibiotics delivered orally whenever it is necessary, then select the checkbox labeled “Administer Antibiotics By Mouth, As Necessary.” Select the third box of this set if the Nevada Declarant intends to accept antibiotics intravenously as needed.

In “B. Artificially Administered Fluids And Nutrition,” the topic of keeping the Nevada Declarant’s nutrient and fluid levels consistent must be discussed. If the Nevada Declarant refuses a feeding tube, then select the option at the top of the left-hand column. If he or she refuses “IV Fluids” then the checkbox on the top right must be selected.  A trial period can be defined for either receiving nutrients/hydration with a feeding tube of intravenously by selecting the “Defined Trial Period Of Feeding Tube” or “Defined Trial Period OF IV Fluids” If the Nevada Declarant approves of the use of a “Long Term Feeding Tube” or a long term administration of IV fluids to deliver nutrition and vital liquids, then the last checkbox on the left or the last one on the right must be selected. Additional instructions concerning artificial food and water being administered can be supplied to the “Other Instructions” line provided. In “C. Other Limitations Of Medical Interventions,” some basic diagnostic tests that require the Declarant’s approval are presented using two columns of checkboxes. The Nevada Declarant should select each checkbox corresponding to a procedure he or she wishes to deny. Thus, if the Patient refuses admission to an intensive care unit and refuses to have lab work done then the checkboxes labeled “No Intensive Care Admission” and “No Lab Work” should be selected. The Nevada Declarant should select the “No X-Ray” checkbox and the “Not Antiarrhythmic Drugs” if he or she does not wish to be x-rayed or be given drugs to regulate his or her heartbeat. To deny the use of an IV and/or Dialysis, the Nevada Declarant may mark the checkbox labeled “No IV” and/or “No Dialysis” to indicate this. If the Nevada Declarant intends to deny being administered artificial food or hydration then the checkbox “No Hyperalimentation” must be selected. Finally, the Nevada Declarant can select the final checkbox to indicate he or she wishes that “No Electrolyte Or Acid/Base Corrective Measures” are taken when either of these functions fails in his or her body. If the Nevada Declarant has any “Other Limitations Of Medical Interventions” included in this declaration, they should be included on the blank line labeled “Other Instructions”  The third item’s checkbox, labeled “Full Treatment” should be selected if the Nevada Declarant has no objections to any treatments that will be deemed necessary to keep him or her alive. “Additional Instructions” regarding this desire can be furnished to the blank line underneath this checkbox. 

 

Step 32 – Gain The Nevada Physician’s Signature Before Continuing

In “Section C Physician Signature” the attending Nevada Physician will need to prove his aid in the completion of this form as well as his or her belief that these are appropriate measures for Nevada Medical Staff seeking response guidance with the Patient. The first row of boxes in this section requires the current “Date” entered the signature of the Physician produced as well as his or her printed name.  The second row of “Section C. Physician Signature” seeks a record of the “Physician Office Address,” “Physician Phone,” and “Physician License No.” The top of the second POLST page requires verification of the concerned Patient’s identity. Thus, record the Nevada Declarant’s full name on the “Patient Name” line then his or her birthday on the “DOB” line. 

 

Step 33 – State The Nevada Declarant’s Organ Donor Status

If the Nevada Declarant wishes to donate his or her organs upon death and this fact has been stated on his or her State Issued ID or Driver’s License, then the checkbox directly underneath the words “Organ Donation” should be selected.  If there are “Other Instructions” regarding the Nevada Declarant’s anatomical gifts, then supply them on the blank line provided. 

 

Step 34 – Report If Additional Declarations Have Been Dispensed By The Nevada Principal

If the Nevada Declarant has issued or issuing an Advance Directive, then check the “Yes” box in “Section E Advance Directive” If not then check the “No” box and continue to Section F. If a Nevada Advance Directive has been set in place or is being set in effect, then it must be indicated as to whether it is registered with the Secretary of State. If not, then select the box labeled “No.” If the Nevada Declarant has registered an advance directive with the Secretary of State, then select the box labeled “Yes” and record the Nevada Advance Directive’s “Registration No.” on the blank line.  If the Nevada Declarant has an advance directive registered with an Entity other than the Nevada Secretary of State, then dispense the concerned document’s registration information including the name of the Institution where it is registered, and the number used to identify it. Record the full name of the Nevada Attorney-in-Fact over Health Care on the “Appointed Agent #1” line then supply his or her “Telephone No.” on the blank line that follows. It is strongly recommended to record the full name and telephone number of either a second Nevada Health Care Attorney-in-Fact (if two are have been set to work together) or to present the identity of the Alternative Attorney-in-Fact on the lines labeled “Appointed Agent #2” line and the accompanying “Telephone No.” line.  Item 2 of this section will state that when the Nevada Declarant is unconscious and no Attorney-in-Fact has been set in place then, treatment will be decided by Nevada law, while the third item “Court-Appointed Guardian” requests that if the Patient does not have a Court Appointed Guardian set in place, that the “No” box is checked. If the Nevada Declarant has a Court-Appointed Guardian set, then mark the box labeled “Yes” and present the Guardian’s name on the blank line to the right. In addition to naming the Nevada Declarant’s Court Appointed Guardian, the “Telephone No.” where the Guardian can be reached must be furnished. 

 

Step 35 – Proper Declarant Approval Must Be Delivered To This DNR

Now that the Nevada Declarant’s POST has been furnished with the information it requests and approved by the Nevada Physician in attendance, the Declarant will have to execute it properly. This means the Nevada Declarant must read the first statement in “Section F Signature” If he or she wishes to verify this statement and the POLST it refers to is accurate, then the Nevada Declarant must sign the “Signature” line and dispense the current “Date” next to it. This action must take the place before a Witness.  The identity of the Nevada Declarant or Patient has been treated as one and the same however, in some cases, the Declarant may not have the mobility to complete this form or may not be conscious but has set instructions for this form to be issued. Therefore, the Witness must select a checkbox defining the Declarant from the choices provided under the bold words “Consent For Sections A And B Above Were Discussed With And Given By” Select the first checkbox if the Nevada Declarant and POST Patient are the same person, the second checkbox if the Declarant is the POST Patient’s “Spouse,” the third checkbox if the Declarant is the Child (18 years and older) of the Patient, or the fourth checkbox if he or she “Court-Appointed Agent” If none of these options apply then continue to the next row of choices. Select the “Parent Of Minor” if the Declarant is the Patient and is under eighteen years old, if the Declarant is the Nevada Principal’s “Health Care Agent (DPOA)” (see example) or Health Care Attorney-in-Fact, then select the second checkbox on this row. If none of these titles accurately defines the Declarant then, mark the box labeled “Other” and furnish an independent definition to the blank line provided.  After identifying the Nevada Declarant, the Witness must sign the “Witnessed By” line then record the “Date” when he or she submitted the required signature.  Finally, the Preparer (You) must self-identify in the “Preparer’s Information” section by supplying your name to the blank line labeled “Preparer’s Name (Print)” then recording the current “Date” on the blank line to the right. After supplying your printed name and signature date, sign the “Signature Of Person Preparing Form” line. Upon giving the Patient the information needed to complete this form and submit it to the Living will Lockbox, he or she must initial the box in the right margin of “Section G Registry.”

 

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