Medical Power of Attorney Form

Medical Power of Attorney Form

Authorize a healthcare agent to make medical decisions on your behalf.
NRS240A DISCLAIMER - Read carefully.

I, DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.
Principal's Full Legal Name*

First NameMiddle NameLast NameSuffix
Principal's Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Principal's Date of Birth*

MonthDayYear
Date
Healthcare Agent's Full Legal Name*

First NameMiddle NameLast NameSuffix
Relationship to Principal (e.g., spouse, friend, etc.)*
Healthcare Agent's Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Healthcare Agent's Phone Number*
Please enter a valid phone number.
Alternate Agent's Full Legal Name (if any)

First NameLast Name
Relationship to Principal (Alternate Agent)
Alternate Agent's Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Alternate Agent's Phone Number
Please enter a valid phone number.
Scope of Authority Granted to Healthcare Agent*
Limitations or Special Instructions (if any)
Effective Date of This Medical Power of Attorney*

MonthDayYear
Date
Organ Donation Preferences*

I wish to donate any organs or tissues needed for transplantation or research.I do not wish to donate my organs or tissues.Other (please specify)
Printed Name of Witness 1 (Optional)
Printed Name of Witness 2 (Optional)
NRS240A DISCLAIMER - Read carefully.

I, DEBORAH BARNHART, DOING BUSINESS AS DPSOFNORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOTACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.
I understand that Deborah Barnhart, dba DPS of NorthernNevada, is not an attorney and is acting solely as a legal document preparer.
Name*

First NameMiddle NameLast NameSuffix
Should be Empty:

Medical Power of Attorney Form

NRS240A DISCLAIMER - Read carefully.

NRS240A DISCLAIMER - Read carefully.