Nebraska Medical Power of Attorney
This Medical Power of Attorney is made in accordance with Nebraska state laws regarding advance directives. This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip Code: ____________________________
- Date of Birth: ____________________________
Agent Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip Code: ____________________________
- Phone Number: ____________________________
Durability of Power of Attorney:
This Medical Power of Attorney shall remain in effect even if I become incapacitated, unless revoked by me in writing.
Authority Granted:
I grant my agent the authority to make medical decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Making decisions about life-sustaining treatments.
Signature of Principal:
______________________________
Date: ____________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness 1 Name: ____________________________
- Witness 1 Signature: ____________________________
- Witness 1 Date: ____________________________
- Witness 2 Name: ____________________________
- Witness 2 Signature: ____________________________
- Witness 2 Date: ____________________________
Notary Public:
State of Nebraska
County of ____________________________
Subscribed and sworn before me this _____ day of ____________, 20__.
______________________________
Notary Public Signature
My commission expires: ____________________________