[THIS SECTION IS FOR YOUR INFORMATION ONLY. IT WILL NOT BE PRINTED.]
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record. It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate. The Health Care Power of Attorney should be reviewed: if the Agent or the Alternate Agent is no longer able to serve; if the Agent is your spouse and you become separated or divorced; or if you wish to revise your desires as stated in the document.
HCP_NV15
{NEXT_?}
This section contains a Disclosure Statement which explains the purpose and consequences of this Durable Power of Attorney for Health Care. The Disclosure Statement will appear on the printed document and must be read and understood by the Principal before he or she signs the Durable Power of Attorney for Health Care. Press [Ctrl+F1] for more information.
HCP_NV01
{NEXT_?}
DESIGNATION OF HEALTH CARE AGENT. Unless the person is also your spouse, legal guardian or related to you by blood, none of the following may be designated as your Attorney-in-Fact: (1) your treating provider of health care, (2) an employee of your treating provider of health care, (3) an operator of a health care facility, or (4) an employee of an operator of a health care facility.
HCP_NV02
HNV02005
Name: |
HCP_NV02
=Who is this Health Care Power of Attorney being prepared for?
Enter the name of the person who will act as Attorney-in-Fact or use the P.I. Manager to select and paste a record. The Attorney-in-Fact will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
HNV02015
Relation:#|
HCP_NV02
FWhat is the Attorney-in-Fact's relationship, if any, to the Principal?
{NEXT_?}
HCP_NV03
{NEXT_?}
HCP_NV04
{NEXT_?}
SPECIAL PROVISIONS AND LIMITATIONS. Your Attorney-in-Fact is not permitted to consent to any of the following: commitment to or placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. If there are any other types of treatment or placement that you do not want your Attorney-in-Fact's authority to give consent for or other restrictions you wish to place on his or her Attorney-in-Fact's authority, you should list them in this document. If you do not write any limitations, your Attorney-in-Fact will have the broad powers to make health care decisions on your behalf, except to the extent that there are limits provided by law.
HCP_NV05
HNV05002
Special provisions and limitations:#|
HCP_NV05
jWhat are the limitations on the Attorney-in-Fact's authority to make decisions on behalf of the Principal?
{NEXT_?}
Yes, on the followingdate: |
HCP_NV06
3Will this power of attorney end on a specific date?
Enter an X to include the date on which this power of attorney will cease to be effective. (Unless a date is specified, this power of attorney will exist indefinitely.)
{NEXT_?}
With respect to decisions to withhold or withdraw life-sustaining treatment, your Attorney-in-Fact must make health care decisions that are consistent with your known desires. If your desires are unknown, your Attorney-in-Fact has the duty to act in your best interests; and, under some circumstances, a judicial proceeding may be necessary so that a court can determine the health care decision that is in your best interests.
The next few questions deal with the Principal's desires and the Agent's authority in regard to life-sustaining treatment, artificial feeding, and other health care decisions. Press [Ctrl+F1] for more information.
HCP_NV07
HNV07002
Yes, any and all treatments are requested.
HCP_NV07
kWill the Principal's life be prolonged to the greatest extent possible, without regard to recovery or cost?
HNV07003
Yes, my Attorney-in-Fact will be authorized.
HCP_NV07
Will your Attorney-in-Fact be authorized to direct the discontinuation of life-sustaining treatment if you are permanently unconscious?
HNV07004
Yes, my Attorney-in-Fact will be authorized.
HCP_NV07
Will your Attorney-in-Fact be authorized to direct the discontinuation of life-sustaining treatment if your condition is incurable?
HNV07005
Yes, treatment is requested.
HCP_NV07
mDo you wish to receive artificial nutrition or hydration if withholding such treatment would result in death?
HNV07006
Yes, my Attorney-in-Fact will be authorized.
HCP_NV07
wWill your Attorney-in-Fact be authorized to decide if and when life-sustaining treatments may be withdrawn or withheld?
HNV07007
Other desires:#|
HCP_NV07
LWhat other desires, if any, do you wish to state regarding your health care?
If desired, use this space to specify desires concerning health care which are not otherwise contained in this document. For example, specific procedures that you do or do not desire, your values, religious preferences, or any limits on the Agent's authority.
{NEXT_?}
HNV07007
Yes, include life-sustaining treatment section.
HCP_NV07
FDo you wish to state your desires regarding life-sustaining treatment?
GWho, if anyone, will be appointed as Second Alternate Attorney-in-Fact?
If desired, enter the Second Alternate Attorney-in-Fact's name or use the P.I. Manager to select and paste a record. You do not have to name a Second Alternate Attorney-in-Fact.
{NEXT_?}
HNV08027
Yes, include Alternate section.
HCP_NV08
7Do you wish to designate an Alternate Attorney-in-Fact?
Enter the Principal's city or edit the information as desired.
{NEXT_?}
WITNESS RESTRICTIONS. None of the following may be used as a witness: (1) the person you designate as the Attorney-in-Fact, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a health care facility, (5) an employee of an operator of a health care facility. At least one of the witnesses must not be related to the Principal by blood, marriage, or adoption, nor entitled to any part of the estate of the Principal upon the death of the Principal under a will now existing or by operation of law.
HCP_NV14
HNV14003
WitnessesNotary
HCP_NV14
/Who will acknowledge the Principal's signature?
Enter an X if two witnesses will be signing this document. By signing this section, the witnesses declare that they were present when the Principal signed this document.
Enter an X if a Notary Public will be signing the document.
HNV14000
{NEXT_?}
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_NV14
2What are the names and addresses of the witnesses?
(.txt)