Nebraska Medical Power of Attorney Form

The Nebraska medical power of attorney form is a document that is completed by a Principal to appoint an Agent/Attorney In Fact, to oversee and make decisions for the Principal’s health care in the event the Principal is no longer able to communicate their own desires for their end of life wishes.This document will not allow the Agent to make any decisions with regard to the finances or any of the Principal’s real or personal property.

The Principal may wish to consider speaking with an Attorney before completing and signing this document to ensure that they are very clear regarding the legal implications that could occur. Legal counsel will be able to better educate the Principal prior to finalizing of their end of life wishes.

This document must contain the signatures of two unrelated witnesses and must be signed before a notary public. This document may be revoked by the Principal at their discretion which would immediately stop any decision making powers of the Agent according to the date of revocation entered into the notice.

How to Write

Step 1 – Agent Appointment – Provide:

  • The name of the selected Agent
  • Agent’s Address
  • Agent’s Telephone Number
  • AND
  • The name of a Successor Agent (optional)
  • Successor’s Address
  • Telephone Number

Step 2 – Principal’s Instructions or Limitations –

  • The Principal must enter the information or limitations for which the Agent is expected to comply

Step 3 – Instructions Pertaining to Life Sustaining Treatments – Enter:

  • The wishes of the Principal with regard to life sustaining treatments, of which the Agent(s) will be expected to comply

Step 4 – Artificially Administered Nutrition and Hydration Instructions –

  • The Principal must enter into the lines provided, any instructions with regard to artificially administered nutrition and hydration of which the Agent’s will be expected to comply
  • Read the statement at the end of the document, if in agreement, the Principal must enter their Signature and date the signature in mm/dd/yyyy format

Step 5 – Declaration of Witnesses and Notarization -The unrelated witnesses must read the Witness Declaration. If in agreement enter the following:

  • Each witness must submit their respective signatures
  • Date each signature in mm/dd/yyyy format
  • Each witness must enter their printed or typed name

Notarization –

  • Once the Notary has witness signatures of all of the signatories required to sign the document, the Notary Public shall then complete the remainder of the document so that it may be acknowledge when presented by the Agent(s).