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Nevada Medical Power of Attorney Form

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Nevada Medical Power of Attorney Form

Updated August 09, 2023

A Nevada medical power of attorney is a document that, when properly executed, allows another person to make healthcare-related decisions on your behalf if you become incapacitated. While it may be unpleasant to think of any scenarios where such paperwork is needed (i.e. complications during a surgery or an accident that renders you incommunicative), many would consider having such paperwork in place a wise precaution and astute planning.


How to Write

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1 – The Medical Authority Paperwork On This Page Should Be Downloaded

Locate the buttons beneath the image preview of this form. Select the correct format then, open it and download the form. You may work on this form on screen or print out a copy(ies) at your discretion.

2 – The Healthcare Agent’s Identity Should Be Reported In Article I

Article I will have several blank lines. The first blank line is reserved for the Full Name of the Principal who is appointing a Health Care Agent. Make sure to enter this Name exactly as it appears on his or her Identification and Insurance Records. Next, you will need to enter the Full Name, Complete Address, and Current Telephone Number of the Health Care Agent on the blank lines labeled “Name,” “Address,” and “Telephone Number.”

3 – Specific Instructions Should Be Reported If The Principal Intends To Apply Them To This Appointment

The next set of blank lines, following the statement beginning with “In Exercising The Authority Under This Durable Power Of Attorney…,” report any and all Provisions or Limitations the Principal wishes applied to the Health Care Agent’s Powers and Decision Making Process not covered by this document. This will be an opportunity for the Principal to make sure any special circumstances are handled correctly.

4 – Document The Duration Of The Health Care Agent’s Powers In Article 5

If the Principal wishes the Health Care Powers here to terminate automatically upon a specific Date, this Termination Date should be reported on the first blank space in Article 5.

3 – Article 6 Requires The Principal’s Attention Regarding Various Scenarios

Now, if the Principal wishes his or her life to be prolonged regardless of his or her condition, consequences of the lifesaving procedures, or the recovery factors involved, he or she must initial the blank space in Item 1.

If the Principal does not wish his or her life sustained or prolonged when diagnosed as being in an irreversible coma or permanent vegetative state, then he or she should initial the blank line in Item 2.

The Principal may decide the Health Care Agent should not allow for long-term life-sustaining or life-prolonging treatments to be administered if he or she has been diagnosed with a Terminal Condition (a medical condition of which there is no cure). If so, then he or she should initial the blank line in Item 3.

If the Principal wishes to receive artificial Nutrition and Hydration even after all Life-Sustaining Treatment has failed, the Principal should initial Item 4.

If the Principal does not wish to continue Life Sustaining of Prolonging Treatments when the Treatment Results are overly burdensome, then, he or she should initial Item 5.

The final area of this Article will provide several blank lines so that any specific instructions regarding Life-Prolonging Treatments the Principal wishes the Health Care Agent to follow should be recorded.

4 – Report An Alternative Health Care Agent If One Has Been Determined

If an Alternative Health Care Agent has been arranged to assume the Primary Health Care Agent Role (in the event the Primary Health Care Agent can no longer act as such), then declare the Identity of each one in Article 7. Two defined sections “A” and “B” have been provided for this purpose. Use “A. First Alternative Agent,” to report the Full Name, Address, and Telephone Number of the first Alternative Agent to be contacted when the Primary Agent is unavailable. If a second Alternative Agent has been determined then, use the appropriately labeled blank lines in “B. Second Alternative Agent” to record his or her information.

5 – Article 8 Allows The Principal To Properly Execute This Form

The Principal will need to authenticate the intentions and statements in this form. This will be accomplished through his or her Dated Signature. First, on the blank line labeled “Date,” the Principal will need to enter the Date of his or her Signature. On the next available blank line in this section, the Principal will need to report the City and State where he or she is signing this Appointment Form. Finally, the Principal should sign his or her Name on the blank line labeled “Signature.”

The following articles should be read through carefully. The Principal has the ultimate say in what should be considered part of this form (so long as his or her wishes remain within the confines of the law) however, if he or she wishes to remove or alter any parts of Articles 9 through 12, it would be considered wise to consult an attorney before doing so.

Article 13 can only be satisfied by a Notary Public who is present at the time of the Principal Signing. This entity will be able to verify the information appropriately then notarize the Principal Signing.

This document will conclude with two separate Witness Statements. Each one will seek to verify that each Witness has seen the Principal Sign this document and that each one meets the requirements for being a Witness.

Locate the statement beginning with the words “I Declare Under Penalty That The Principal Is Personally Known To me…” Here there will be two sections (“Witness #1” and “Witness #2”) so that each Witness who can agree with this statement may Sign his or her Name, Print his or her Name, and enter his or her “Residential Address.” Following this, each Witness must provide the Date of his or her Signature on the blank line labeled “Date.”

Now, locate the statement beginning with “I Declare Under Penalty Of Perjury That I Am Not Related To The Principal.” Each Witness who agrees with this statement should Sign and Print his or her Name then, record his or her Address. Finally, the Date of his or her Signature should be entered on the Date line.