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Durable Power of Attorney for Health Care

Including Advanced Directive to Physicians and Designation of Personal Representative under HIPAA

Download the form here.

WARNING TO PERSON EXECUTING THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

  1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR ATTORNEY-IN-FACT (“HEALTH-CARE AGENT”) THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU INCLUDES CONSENT, REFUSAL OF CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.
  2. THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO ACT CONSISTENT WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE UNKNOWN, TO ACT IN YOUR BEST INTERESTS.
  3. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THE POWER OF THE PERSON YOU DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YOU ALIVE.
  4. THIS POWER WILL EXIST INDEFINITELY FROM THE DATE YOU EXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU BECOME ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.
  5. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, SO LONG AS YOU HAVE SUFFICIENT MENTAL CAPACITY TO GIVE INFORMED CONSENT, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY BE STOPPED IF YOU OBJECT.
  6. YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON DESIGNATED IN THE DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THAT PERSON OF THE REVOCATION ORALLY OR IN WRITING.
  7. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER PROVIDER OF HEALTH CARE ORALLY OR IN WRITING.
  8. THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.
  9. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH
  10. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

1. DESIGNATION OF HEALTH-CARE AGENT AND PERSONAL REPRESENTATIVE.

I, the “Principal” named below, do hereby designate and appoint the “Health-care Agent” named below as my attorney-in-fact and as the guardian of my person to make health care decisions for me as authorized in this document. “Agent,” “health-care agent,” and “attorney-in-fact” are used interchangeably in this document to refer to the health-care agent and any alternate serving under this instrument. I hereby designate the health-care agent (including each alternate designated herein) as my “personal representative” for purposes of HIPAA (as defined in subparagraph 13.f).

PRINCIPAL
HEALTH-CARE AGENT (Include name, address & telephone.)
FIRST ALTERNATE HEALTH-CARE AGENT (Include name, address & telephone.)
SECOND ALTERNATE HEALTH-CARE AGENT (Include name, address & telephone.)
THIRD ALTERNATE HEALTH-CARE AGENT (Include name, address & telephone.)

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document, I hereby create a durable power of attorney by appointing the person designated above (including each alternate named herein) as my health-care agent to make health care decisions for me. This document is effective immediately and shall not be affected by my subsequent incompetence, disability, or other incapacity.

3. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to the health- care agent named above full power and authority to make health care decisions for me before or after my death, including: consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition, subject only to the limitations and special provisions, if any, set forth in paragraph 4 or paragraph 7. If I have not indicated with my initials that I agree or disagree with an option that is stated in this form, my intent is to leave the decision to my health- care agent, whose decision shall be final. I specifically authorize my health-care agent to:

a. Confer with health-care providers and professionals regarding my health and care.

b. Confer with and exchange personal information with any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse.

c. Authorize or decline to authorize surgery and/or the administration of medications (subject to the provisions of paragraphs 4 and 7).

d. Authorize or refuse to authorize my admission to a hospital, convalescent center, nursing home, hospice, or other health-care institution (other than commitment to a mental health treatment facility and subject to the provisions of paragraphs 4, 6, and 7).

e. Arrange for my long-term care (subject to the provisions of paragraph 6).

f. Review and receive copies of personal information (as defined in subparagraph 13.i) and to release or authorize the release of such information to others, as my health-care agent shall deem appropriate. I acknowledge that information disclosed by a healthcare provider or other covered entity may be redisclosed and may no longer be subject to the privacy rules provided by law (including 45 CFR § 164).

g. Authorize one or more physicians or psychologists to examine me for the purpose of determining whether or not I am incompetent, am disabled, am incapacitated, have the legal and/or mental capacity to make a will, trust, other legal document, or modification thereof, have the legal and/or mental capacity to serve as a fiduciary, and to release the findings of such examination to such persons or entities as my agent shall deem appropriate.

h. Sign documents on my behalf to carry out the powers granted herein, including waivers or releases of liability required by any health care provider or any custodian of records.

i. Visit me in a medical facility, facility for the dependent or home for individual residential care. I hereby instruct all staff of a medical facility, facility for the dependent or home for individual residential care in which I am a patient to admit my health-care agent to my room and afford said agent the same visitation rights as are provided to members of my family who are legally related to me during my time as a patient.

j. Each person designated as an alternate health-care agent herein (including each individual named as a co-agent) shall have the same powers as the acting health-care agent except as to the making of decisions hereunder, including the right to receive personal information, to confer with medical care providers, and to be permitted visitation rights.

4. SPECIAL PROVISIONS AND LIMITATIONS. In exercising the authority under this durable power of attorney for health care, the authority of my health-care agent is also subject to the following special provisions and limitations: (Initial here if there are no other limitations:__________) (Initial here if the following limitations apply:__________)

5. DURATION. This power of attorney will exist indefinitely from the date I execute this document until revoked by me in writing.

6. STATEMENT OF DESIRES AS TO LONG-TERM CARE AND CAREGIVERS. With respect to my long-term care, my health-care agent is authorized to act in my best interest, as my health-care agent may determine. I specifically authorize my health-care agent to make decisions relating to my long-term care, subject to the statements in this paragraph 6 that I have initialed. If I have not initialed a particular statement, any decisions related to that statement shall be made in my agent’s discretion. If, after consulting with my physician, other health-care providers, and my family, my health- care agent determines that I need long-term care, my health-care agent shall have the full and unrestricted discretion to select my: physician and other health-care providers; health-care facilities; caregivers; and/or long-term care facility.

a. It is my wish that I never be placed in a long-term care facility and that my long-term care be provided either in my own home or in the home of my caregiver.

As to 6.a: I agree:______________. I disagree______________. As my Agent decides ______________.

b. For the purposes of subparagraph 6.a, “my home” may include an assisted-living facility.

As to 6.b: I agree:______________. I disagree______________. As my Agent decides______________.

c. ______________ .(Initial here if the following statement of other desires applies):

7. STATEMENT OF DESIRES AS TO LIFE-SUSTAINING PROCEDURES. With respect to decisions relating to the withholding and/or withdrawal of life-sustaining procedures, my health-care agent is authorized to act in my best interest, as my health-care agent may determine. I specifically authorize my health-care agent to make decisions relating to the withholding and/or withdrawal of life-sustaining procedures, subject to the remaining provisions of this paragraph 7. I have indicated my desires by initialing below that I agree or disagree with the following statements, which shall constitute a directive to my family and loved ones, to each health-care agent appointed hereunder, to my physicians, and to health care providers and all others who may be responsible to provide medical care or make decisions related thereto. If I have not indicated that I agree or disagree with a particular statement, any related decision shall be left to my health- care agent’s discretion. It is my intention that this directive be honored by my family, by my attending physician(s), and by all other persons as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences of my refusal. As provided in NRS 449.613(2), it is also my intention that this declaration serve as a declaration under the Uniform Act on Rights of the Terminally Ill under the provisions of NRS 449.535 to 449.690, inclusive, as most recently amended.

a. I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the cost of the procedures.

As to 7.a: I agree:______________. I disagree______________. As my Agent decides______________.

b. If I have an incurable or terminal condition or illness and there is no reasonable hope of my long term recovery or survival, I desire life-sustaining or prolonging treatments be withheld or withdrawn, and that I be permitted to die naturally.

As to 7.b: I agree:______________. I disagree______________. As my Agent decides______________.

c. If I am in a coma which my doctors have reasonably concluded is irreversible, I desire that life-sustaining or prolonging treatments be withheld or withdrawn, and that I be permitted to die naturally. I do not want life-sustaining procedures used if there is no reasonable hope that I will regain my ability to understand and respond to my circumstances.

As to 7.c: I agree:______________. I disagree______________. As my Agent decides______________.

d. I do not desire treatment to be provided and/or continued if the burdens of the treatment outweigh the expected benefits. My health-care agent and health-care providers are to consider the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of the possible extension of my life.

As to 7.d: I agree:______________. I disagree______________. As my Agent decides______________.

e. I want efforts to be made to relieve my pain, even if life-sustaining procedures are withheld or withdrawn. My health-care agent is authorized to consent to pain-relief medications and treatments, even if there are adverse side effects and even if there is a potential for habituation, addiction, or dependence.

As to 7.e: I agree:______________. I disagree______________. As my Agent decides______________.

f. When life sustaining or prolonging treatments are to be withdrawn and/or withheld, then as to artificially administered nutrition and hydration: (You may only agree with one of the following.)

i. Artificially administered nutrition and hydration may never be withdrawn or withheld.

As to 7.f.i: I agree:______________. I disagree______________. As my Agent decides______________.

ii. Artificially administered nutrition and hydration may be withdrawn or withheld unless the withdrawal or withholding would result in death from dehydration or starvation rather than from my existing disease, illness or injury.

As to 7.f.ii: I agree:______________. I disagree______________. As my Agent decides______________.

iii. Artificially administered nutrition and hydration may be withdrawn or withheld even if the withdrawal or withholding would result in death solely from dehydration or starvation rather than from my existing disease, illness or injury.

As to 7.f.iii: I agree:______________. I disagree______________. As my Agent decides______________.

g. (Initial here if the following statements of other desires applies):______________.

8. POWER TO NEGATE DIRECTIVE. Notwithstanding anything to the contrary herein, I reserve the right to make any medical or health-care decision for myself so long as I have sufficient mental capacity to give informed consent with respect to the particular decision, and I reserve the right to object to a treatment and to object to the withholding or stopping of a treatment.

9. DESIGNATION OF ALTERNATE HEALTH-CARE AGENT. If the person designated above as my health-care agent is unavailable, cannot be contacted, or is otherwise unwilling or unable to make health care decisions for me, then the alternate health-care agents shown in paragraph 1, above, shall act to make health care decisions for me as authorized in this document. The alternate health-care agents shall be contacted in the order named; provided, that the first available health-care agent may serve without further documentation. If no named health-care agent (including an alternate) is available, able, and willing to serve, the desires expressed herein — including the applicable provisions of paragraphs 4, 7, and 11 — shall nevertheless remain in effect.

10. AGENTS ACTING JOINTLY. If I have designated agents to act jointly, the decisions made hereunder shall be made by majority vote of the agents; provided, however:

a. Any agent may act alone if the other agent(s) cannot be contacted or refuse to act or an urgent decision must be made or it is otherwise impractical to contact the other agent(s).

b. Any decision to withhold or withdraw life-sustaining treatments or procedures in accordance with the provisions of section 7 shall be made by the unanimous decision of my health- care agents.

11. UNIFORM ANATOMICAL GIFT ACT. Pursuant to NRS 451.500 et seq., I hereby make a gift of my physical remains pursuant to the Nevada Uniform Anatomical Gift Act:

a. (Initial here if the following applies:______________) I direct that no gift be made of my physical remains or any part thereof. (If you initial this subparagraph, no gift of your physical remains shall be made, and you should skip the balance of this paragraph 11.)

b. No gift of my physical remains shall be made for any purpose listed below if I have initialed under the “No” column next to that purpose. I make a gift of my physical remains for the purposes next to which I have initialed in the “Yes” column and, with the consent of my health-care agent, for the purposes next to which I have initialed in the column labeled “As my agent decides”.

Purpose Yes No As my agent decides
The treatment of or therapy for illness or disease of a living human.
Transplanting into a living human being.
Medical research
Scientific research

c. Subject to the approval of my health-care agent (unless no health-care agent is able and willing to act):

i. The portion of my remains donated shall include all body parts, humors, and tissues that can be used for the purposes indicated.

ii. This anatomical gift is made to any physician, dentist, hospital, university, clinic, or organization that can use the donated organs for the specified purposes.

d. This anatomical gift is made on the condition that all expenses associated with this gift shall be borne by the donee.

12. DISPOSITION OF MORTAL REMAINS; MEMORIAL SERVICE. In compliance with NRS 451.024(5), I hereby grant to my health-care agent the power to direct the disposition of my mortal remains after my death, subject to the provisions of paragraph 11 herein and the following:

a. I direct that my mortal remains be buried.

As to 12.a: I agree:______________. I disagree______________. As my Agent decides______________.

b. I direct that my mortal remains be cremated.

As to 12.b: I agree:______________. I disagree______________. As my Agent decides______________.

c. Initial one of these choices:

i. ______________ I do not want a funeral or other memorial service.

ii. ______________ After conferring with my family, my health-care agent is directed to make such arrangements for a funeral or other memorial service as my health- care agent deems appropriate.

iii. ______________ My health-care agent is directed to make the arrangements for a funeral or other memorial services in accordance with the instructions that are attached hereto.

d. ______________ (Initial here if the following statements of other desires applies):

13. DEFINITIONS.

a. “Artificially administered nutrition and hydration” includes parenteral feeding, intravenous feedings, and endotracheal or nasogastric tube use.

b. A “beneficiary” of mine is anyone who will receive any property or other economic benefit by reason of my death, including, but not limited to: a beneficiary under a will or trust; a joint tenant or other person holding property jointly with me in a form that includes a right of survivorship; and/or a beneficiary under a contract, such as a life insurance contract, an individual retirement account or other transfer-on-death arrangement.

c. “Caregiver” refers to the individual who is responsible for my daily physical care when I am in need of long-term care that is not being provided in an institution such as a hospital, hospice, nursing home, or convalescent center.

d. “Coma” shall include any comatose condition, persistent vegetative state, or permanent unconsciousness.

e. “Health-care provider” includes any person or entity that provides any services related to my health care, including any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, or pharmacy. The term also includes any person or entity that is considered a health-care provider under HIPAA.

f. “HIPAA” refers to the federal Health Insurance Portability and Accountability Act of 1996 and related regulations (42 USC § 1320d and 45 CFR §§ 160-164).

g. “Life-sustaining procedure” refers to any treatment or procedure which utilizes mechanical or intervention that, when administered to a patient, serves only to prolong the process of dying. It includes, but is not limited to, chemotherapy, radiation treatments, cardiopulmonary resuscitation, surgery, dialysis, use of a respirator, blood transfusions, antibiotics, pacemakers, insulin pumps, and transplants.

h. “Long-term care” refers to physical care that I am unable to provide for myself that is anticipated to be required for at least 90 days or, if shorter, the balance of my anticipated life expectancy. Long-term care excludes hospitalization and hospice care, but it refers to care and treatment in a nursing home, convalescent center, assisted-living facility, or in my home under the direction of a caregiver.

i. “Personal information” includes, without restriction, any information governed by HIPAA, including private, privileged, protected, or personal health information. “Personal information” specifically includes:

i. All records relating to: my medical history, health-care insurance, and other financial information related to the payment for my health and medical care; life insurance; and other financial information related to the payment for the disposition of my mortal remains and any memorial service.

ii. All of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse.

14. WAIVER OF CONFLICT OF INTEREST. If any designated health-care agent designated herein is a beneficiary of any property interest that might pass to his or her after my death, then I waive any conflict of interest in carrying out the provisions of this Durable Power of Attorney for Health Care that beneficiary may have by reason of the fact that he or she may be a beneficiary of mine.

15. CHALLENGES. If the legality of any provision of this Durable Power of Attorney for Health Care is questioned by my physician, my agent or a third party, then my agent is authorized to commence an action for declaratory judgment as to the legality of the provision in question. The cost of any such action is to be paid from my estate. This Durable Power of Attorney for Health Care must be construed and interpreted in accordance with the laws of the State of Nevada, but I request that it be honored wherever I may require medical treatment.

16. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care.

(BEFORE THIS POWER IS VALID, YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY, AND IT MUST BE WITNESSED BY TWO QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE.)

I sign my name to this Durable Power of Attorney for Health Care on ______________(date) at Las Vegas, Nevada. I understand the full import of this document and I am emotionally and mentally competent to execute it. This document constitutes an affidavit of the declarations made herein, and, in compliance with NRS 53.045 (which permits unsworn declarations to serve as an affidavit without a notary), I declare under penalty of perjury that the foregoing is true and correct.

________________________________________________________

STATEMENT OF WITNESS

You should carefully read and follow this witnessing procedure. This document will not be valid unless you comply with the witnessing procedure. You must use two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as your health-care agent, (2) a provider of health care, (3) an employee of a provider of health care, (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 make the additional declaration set out following the place where the witnesses sign.

I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney for health care in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as health- care agent by this document, and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility, nor an employee of an operator of a health care facility.

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Sign on the line above

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Print name on the line above

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Date

Print residence address below:

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Print name on the line above

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Date

Print residence address below:

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(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.)

I declare under penalty of perjury that I am not related to the principal by blood, marriage, or adoption, and to the best of my knowledge I am not 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.

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Sign on the line above

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Print name on the line above

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Date

Print residence address below:

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Sign on the line above

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Print name on the line above

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Date

Print residence address below:

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Copies: You should retain an executed copy of this document and give one to your health-care agent. A copy should be given to your primary physician for his or her file, and you should also consider giving copies to other health care providers who are currently treating you.

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