DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(Nebraska)
[// GUIDANCE: This template is drafted to comply with Nebraska’s Durable Power of Attorney for Health Care Act, Neb. Rev. Stat. §§ 30-3401 et seq. It is intended for attorney customization and client-specific tailoring before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Grant of Authority
- Scope of Authority & Limitations
- End-of-Life Decisions
- HIPAA Authorization
- Representations & Warranties
- Covenants & Restrictions
- Default; Resignation; Removal
- Liability; Indemnification; Good-Faith Standard
- Dispute Resolution & Governing Law
- General Provisions
- Execution Block
- Witness | Notary Acknowledgment
1. DOCUMENT HEADER
Durable Power of Attorney for Health Care (this “Instrument”) executed as of [EFFECTIVE DATE] (the “Effective Date”) by [PRINCIPAL LEGAL NAME], of [ADDRESS] (“Principal”), in favor of the health-care agent(s) designated herein (each, an “Agent”).
Recitals
A. Principal desires to appoint an Agent to make health-care decisions on Principal’s behalf should Principal lack capacity, in accordance with Neb. Rev. Stat. §§ 30-3401 to 30-3432.
B. Principal affirms this Instrument is executed voluntarily, without duress, and intends it to be a durable power of attorney for health care.
2. DEFINITIONS
“Advance Directive” means any written statement relating to the provision of health care when the declarant is incapacitated, including living wills and this Instrument.
“Capacity” means the ability to understand and communicate health-care decisions, as determined under Neb. Rev. Stat. § 30-3402(5).
“Health Care” has the meaning given in Neb. Rev. Stat. § 30-3402(7).
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. Parts 160 & 164.
“Primary Physician” means the physician selected under Section 3.4 or, if none, the physician who has taken primary responsibility for Principal’s health care.
[Add additional defined terms as needed.]
3. GRANT OF AUTHORITY
3.1 Appointment. Principal hereby designates [PRIMARY AGENT NAME], of [ADDRESS], as primary Agent.
3.2 Successor Agents. If the primary Agent resigns, is incapacitated, unwilling, or unavailable, then [1st SUCCESSOR AGENT NAME] shall serve, followed by [2nd SUCCESSOR AGENT NAME]. Successor Agents shall serve in the order listed and shall not act concurrently unless specifically authorized in Section 3.3.
3.3 Co-Agents. □ Authorized to act jointly. □ Authorized to act independently. [Select one.]
3.4 Determination of Incapacity. Principal’s incapacity shall be determined by (check one):
(a) □ Two licensed physicians, one of whom is Principal’s Primary Physician; or
(b) □ One licensed physician and one licensed psychologist.
3.5 Durable Nature. This Instrument shall remain effective notwithstanding Principal’s subsequent incapacity.
4. SCOPE OF AUTHORITY & LIMITATIONS
Subject to Section 5 and applicable law, Agent is authorized to:
a. Consent, refuse, or withdraw consent to any medical treatment, service, or procedure.
b. Admit or discharge Principal from health-care facilities.
c. Access, receive, and disclose medical records subject to HIPAA (see Section 6).
d. Hire and fire health-care personnel.
e. Make anatomical gift, autopsy, and disposition decisions consistent with Neb. Rev. Stat. §§ 71-4822 et seq.
f. Execute waivers and releases of liability for health-care providers.
Limitation. Agent may not:
• Authorize voluntary sterilization, abortion, or involuntary commitment, unless expressly initialed here: ______ Initials.
• Override any expressly stated limitation in this Instrument.
[// GUIDANCE: Insert additional specific limitations or instructions desired by the Principal.]
5. END-OF-LIFE DECISIONS
5.1 Statement of Intent. Principal’s preferences regarding life-sustaining treatment are (check one and initial):
(a) □ Prolong Life – Employ all life-prolonging measures. __
(b) □ Comfort-Focused Care – Withhold or withdraw life-sustaining treatment if I am in a terminal condition or persistent vegetative state. _
(c) □ Agent Discretion – Permit Agent to decide after consultation with my Primary Physician. ___
5.2 Artificial Nutrition & Hydration. □ Include as life-sustaining treatment. □ Exclude.
5.3 Pain Management. Principal desires adequate pain relief even if it may hasten death, consistent with law.
5.4 Do-Not-Resuscitate (DNR). □ I request a DNR order be issued. □ I do not request a DNR order.
[// GUIDANCE: Nebraska law permits detailed end-of-life instructions; tailor Sections 5.1–5.4 accordingly.]
6. HIPAA AUTHORIZATION
6.1 Authorization. Pursuant to 45 C.F.R. § 164.508, Principal authorizes any Covered Entity to disclose Protected Health Information (“PHI”) to the Agent to the fullest extent permitted.
6.2 Duration. This authorization is effective on the Effective Date and shall not expire unless revoked in writing, surviving Principal’s death to the extent necessary to carry out post-mortem health-care decisions.
6.3 Redisclosure. PHI disclosed may be subject to redisclosure by Agent and may no longer be protected by HIPAA.
6.4 Revocation. Principal may revoke this authorization in writing at any time, except to the extent action has been taken in reliance hereon.
7. REPRESENTATIONS & WARRANTIES
7.1 Principal Representation. Principal warrants:
a. Principal is at least eighteen (18) years of age and of sound mind.
b. This Instrument reflects Principal’s free and voluntary act.
7.2 Agent Representation. Each Agent, by accepting authority, represents:
a. The Agent will act in good faith, consistent with Principal’s known wishes and best interests.
b. The Agent is not disqualified under Neb. Rev. Stat. § 30-3404.
Survival. The representations herein survive revocation or termination for acts taken during the term of authority.
8. COVENANTS & RESTRICTIONS
8.1 Agent’s Duties. Agent shall:
a. Consult with health-care providers and advocate for Principal’s stated preferences.
b. Make decisions consistent with Principal’s spiritual or moral beliefs.
c. Maintain records of significant health-care decisions.
8.2 No Compensation. Agent shall serve without compensation except reimbursement of reasonable out-of-pocket expenses, unless otherwise provided here: [COMPENSATION TERMS OR “N/A”].
8.3 Conflicts of Interest. Agent shall disclose any material conflict and, if conflict exists, step aside in favor of a Successor Agent.
8.4 Third-Party Reliance. Any person may rely on Agent’s instructions absent actual knowledge of revocation or fraud.
9. DEFAULT; RESIGNATION; REMOVAL
9.1 Resignation. Agent may resign by written notice to Principal (if capacitated) and Successor Agent or, if none, to the state probate court of [COUNTY].
9.2 Removal. Principal (if capacitated) or a court of competent jurisdiction may remove an Agent for breach of fiduciary duty, incapacity, or other good cause.
9.3 Vacancy. If all named Agents are unable to serve and no Successor Agent is available, a guardian may be appointed pursuant to Neb. Rev. Stat. §§ 30-2626 et seq.
10. LIABILITY; INDEMNIFICATION; GOOD-FAITH STANDARD
10.1 Good-Faith Standard. An Agent acting in good faith shall not be liable for civil or criminal penalties for health-care decisions made pursuant to this Instrument (Neb. Rev. Stat. § 30-3424).
10.2 Indemnification. Principal agrees to indemnify and hold harmless each Agent from claims, losses, or expenses arising from good-faith exercise of authority, except for willful misconduct or gross negligence.
10.3 Liability Cap. Agent’s liability, if any, shall not exceed the amount of insurance or indemnification actually available, consistent with Section 10.2.
11. DISPUTE RESOLUTION & GOVERNING LAW
11.1 Governing Law. This Instrument and any dispute hereunder shall be governed by the substantive laws of the State of Nebraska (“state_healthcare_law”), without regard to conflict-of-laws principles.
11.2 Forum Selection. Exclusive jurisdiction and venue shall lie in the [COUNTY] Probate Court (the “state_probate_court”).
11.3 Arbitration. Not available. This Instrument does not compel arbitration.
11.4 Jury Waiver. Not applicable; no jury waiver is provided.
11.5 Injunctive Relief. Nothing herein limits a party’s right to seek injunctive relief to enforce health-care directives.
12. GENERAL PROVISIONS
12.1 Amendment; Revocation. Principal may amend or revoke this Instrument at any time by (a) a signed writing; or (b) physical cancellation or destruction. Oral revocation is effective only upon communication to the attending physician.
12.2 Severability. If any provision is invalid, remaining provisions shall remain in full force.
12.3 Integration. This Instrument constitutes the entire durable power of attorney for health care and supersedes prior inconsistent directives.
12.4 Copies. Photostatic or electronic copies shall be deemed originals and may be relied upon by third parties.
12.5 Digital & Counterpart Signatures. Execution by electronic signature and in multiple counterparts is authorized to the fullest extent of law.
13. EXECUTION BLOCK
IN WITNESS WHEREOF, Principal has executed this Durable Power of Attorney for Health Care as of the Effective Date.
Principal:
[PRINCIPAL LEGAL NAME]
Signature Date: _______
14. WITNESS | NOTARY ACKNOWLEDGMENT
[// GUIDANCE: Nebraska requires EITHER two adult witnesses OR a notary acknowledgment.]
A. TWO-WITNESS STATEMENT
The undersigned witnesses affirm that (1) the Principal is personally known to them, (2) the Principal appeared to be of sound mind and under no duress, and (3) the Principal signed or acknowledged signing this Instrument in their presence.
Witness #1: ____ Date: _
Name & Address: ______
Witness #2: ____ Date: _
Name & Address: ______
OR
B. NOTARY PUBLIC
State of Nebraska )
County of __ ) ss.
On this ___ day of ____, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this Instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public
My Commission Expires: _______
[// GUIDANCE: Attach any living will, organ donation form, or additional instructions as schedules.]