Nevada Medical Power of Attorney Form

The Nevada medical power of attorney form is a document whereas the Principal may designate an Agent to oversee the health care of the Principal. This document should be entered into cautiously inasmuch as, once the document is completed and signed by the Principal, the Agent will have complete powers over the health care of the Principal that may withdraw treatment to keep the Principal alive or visa versa, regardless, against the wishes of the Principal.

The Principal must read through paragraphs 1 through 10. If the Principal is unsure if this is at all an action they would like to take, then they must consult with a knowledgeable attorney for clarification prior to completion and signing of this document. However if after reading the first section, the Principal is in agreement, and still wishes to name an Agent, complete the document.

This document must be signed before a notary public or two witnesses. The Principal may revoke this document any time, by providing written notice, delivered to the Agent.

How to Write

Step 1 – Designation of Health Care Agent – Enter:

  • Enter the name of the Principal
  • AND
  • Enter the name of the appointed Agent
  • Agent’s Address
  • Agent’s Telephone Number
  • Read the remainder of the section

Step 2 – Read the Following Titled Sections as Follows:

  • Creation of Durable Powers for Health Care
  • General Statement of Authority Granted
  • Special Provisions and Limitations – in the lines provided, enter the limitations and provisions the Principal would like to grant (or deny) to the Agent

Step 3 – Duration – The Principal must read the first paragraph of this section and enter:

  • The document will become immediately available unless otherwise stated by the Principal –
  • Enter an ending date of the document in mm/dd/yyyy format
  • Read the Statement of Desires and proceed by reviewing all of the following paragraphs, (1 through 8 ) initialing only those powers for which the Principal would like to grant powers.
  • If additional statement must be amended, additions must be made or deletions, enter them into the lines provided at the end of statement number 5.
  • Designate Alternate Agent’s under number 7. –
  • Enter the Names of the Alternate Agents
  • Addresses of Alternate Agents
  • Telephone Numbers

Step 4 – Signature – Sign only before a notary public – The Principal must provide the following:

  • Enter the state in which the document is being executed
  • Enter the date of execution in mm/dd/yyyy format
  • Enter the Principal’s City of residence
  • The Principal must submit their signature

Step 5 – Notarization –

When the document is completed, the Notary shall witness the Principal’s signature and complete the required information in acknowledgement of the validity of the document

Step 6 – If the Principal Prefers to Use Witnesses and No Notary – Enter:

  • All witnesses signatures
  • Witnesses Residential Addresses
  • Print the Witnesses Printed Names
  • Date of Signatures in mm/dd/yyyy format

Step 7 – Copies of Document-

  • The Principal should make copies and provide them to the Agent and Alternate Agents. The Principal must retain the executed copy for their records