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Nebraska Medical Power of Attorney Form

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Nebraska Medical Power of Attorney Form

Updated June 07, 2023

A Nebraska medical power of attorney isi a document that allows a person to appoint another person to make healthcare-related decisions on their behalf. Nebraska Revised Statutes Section 30-3401 is the statute that governs this form. This may serve to provide a certain peace of mind that if one suffers medical events such as car accidents, surgery, or being rendered mentally disabled, his or her medical treatment preferences will be honored. You will want to choose an agent who understands your wishes for health care treatment and will carry out any instructions you may provide.

How to Write

1 – Open The Paperwork To Name A Health Care Representative

Use one of the buttons, below the picture on this page, to open this document. Make sure the Principal’s Preferences have already been determined by the time you are ready to complete this form.

2 – The Introductory Statement of Principal Intent Will Need Several Items Supplied

The first paragraph of this document contains language that sets this paperwork up as a delegation of Principal Power to the Health Care Representative. In order for this wording to be applicable to the situation at hand, several items should be provided on the blank lines this statement contains.

The Legal First, Middle, and Last Name of the Attorney-in-Fact For Health Care, granting Decision Making Power, should be reported on the first blank line. The next blank space in this statement will need to have the Attorney-in-Fact’s entire Home Address presented on it. This should be the Physical Address where the Attorney-in-Fact lives.

Use the third empty line in this statement to enter the Telephone Number of the Attorney-in-Fact/Health Care Agent. This must be a reliable and up-to-date Phone Number. The next three blank spaces will allow a determination of the Successor Attorney-in-Fact For Health Care. This individual will not be granted Principal Decision-Making Power unless the Primary Agent can no longer wield Principal Powers. Use the next three blank spaces to enter the Full Name, Residential Address, and Current Telephone Number of the determined Successor Attorney-in-Fact For Health Care.

3 – Principal Instructions Must Be Provided To Define Principal Preferences

The next four articles will all be direct mandates from the Principal. That is, these are the Principal Preferences the Attorney-in-Fact For Health Care is expected to use as a guideline in the Decision-Making Process used in representing Principal Interest.

First, in Article 2, record the Principal Instructions. This should be a complete detail of the Principal’s Expectations in delivering Power to the Attorney-in-Fact For Health Care. This report should be composed of Instructions for scenarios such as Life-Threatening Medical Conditions, Medical Emergencies, Traumatic Events that Incapacitate the Principal, Terminal Conditions, etc. The Principal should address his or her stance on various Medical Treatments, Procedures, Therapies, and Medical Care that he or she wishes provided, denied, limited and/or Preferred. These instructions will be employed if the Principal will ever be rendered unable to communicate or, otherwise, make his or her own Medical Decisions. The next item, Article 3, is optional. Here, the Principal’s Instructions and Preferences regarding Life-Sustaining Treatment should be focused on. Such subject matter may include scenarios involving Terminal Conditions for which Recovery is not expected or Traumatic Events where the Principal is expected to be dependent on Medical Care to survive. The final item, Article 4, is also optional. If the Principal wishes to address the subject of Artificial Nutrition and Hydration being administered, then he or she may do so on the blank lines in this article. Here, the Principal may document when or if Artificial Nutrition and Hydration should be provided.

4 – The Principal Must Sign This Document To Delegate These Representative Powers

The paragraph in bold print will solidify the Principal’s comprehension and agreement to this paperwork and its contents. He or she should read this statement, Sign his or her Name, and enter the Current Date on the blank line labeled “Signature Of Person Making Designation/Date”

5 – Two Witnesses Or One Notary Public Will Serve to Authenticate The Principal Signing

The next section, “Declaration Of Witness,” should be filled out by the individuals who have watched the Principal sign and date this paperwork. The statement below this heading should be read by each Witness. Once he or she has read and agreed to this statement, each Witness must provide his or her Signature and Signature Date then, Print his or her Name on the line adjacent to the Signature.

If the Principal has decided to provide verification by having his or her Signature Notarized, the following section has been provided for this purpose. The Notary Public obtained will supply the Location of the Principal Signing, the Date of the Principal Signing, and the Individuals present at the Principal Signing. Once the Notary Public has furnished these items, he or she will supply the credentials and seal required for Notarization.