Nevada Medical Power of Attorney
This Nevada Medical Power of Attorney is a legal document that grants authority to an agent to make healthcare decisions on behalf of the principal, in accordance with the Nevada Uniform Power of Attorney Act.
Principal Information
- Full Name: _______________________________
- Address: __________________________________
- City, State, ZIP Code: _________________________
- Date of Birth: ______________________________
- Phone Number: ______________________________
Agent Information
- Full Name: _______________________________
- Address: __________________________________
- City, State, ZIP Code: _________________________
- Phone Number: ______________________________
Alternate Agent Information (If the primary agent is unable to serve)
- Full Name: _______________________________
- Address: __________________________________
- City, State, ZIP Code: _________________________
- Phone Number: ______________________________
In the event that I am unable to make or communicate my health care decisions, the agent named above is authorized to:
- Make any and all health care decisions on my behalf, including treatments for physical or mental conditions.
- Access my medical records necessary for the care and treatment decisions.
- Make decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other forms of health care to keep me alive.
This power of attorney remains active unless it is revoked by me or until my death. My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I specify otherwise here: ____________________________________________________________________.
I, ________________________________ (Principal's Full Name), delegating my authority to the named agent on this day _________________ (Date), affirm that I understand the nature and purpose of this document and the authority it grants.
Principal's Signature: _______________________________ Date: _____________
Agent's Signature: _________________________________ Date: _____________
Alternate Agent's Signature (optional): __________________ Date: _____________
Witnesses
This document must be signed by two witnesses, who attest that the principal is known to them, signed the document in their presence, and appears to be of sound mind and not under duress, fraud, or undue influence.
- Witness #1: Signature: ________________________, Date: _____________, Print Name: ____________________________________
- Witness #2: Signature: ________________________, Date: _____________, Print Name: ____________________________________
Notarization
This document was acknowledged before me on (date) ______________ by (name of principal) _______________________________.
Notary Public: _______________________________
Commission Expires: __________________________
