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Nebraska statutory health care form
Download the August 2026 Nebraska Power of Attorney for Health Care, the statutory form under Neb. Rev. Stat. § 30-3408, for naming an attorney in fact to make health care decisions when you are incapable. Get the form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific power of attorney for health care packet, reviewed against the current Nebraska statute and ready for instant secure access.
Built to the statutory power of attorney for health care form in Neb. Rev. Stat. § 30-3408, not a national generic template.
Stacked two-witness declaration and notary acknowledgment so you can complete either valid path under § 30-3404.
Complete the form on your device, then sign with two qualified adult witnesses or a notary. Your personal details are never entered into an online form builder.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete form text below before purchasing. Your licensed Word and fillable PDF download is delivered after checkout.
POWER OF ATTORNEY FOR HEALTH CARE
Nebraska · Neb. Rev. Stat. § 30-3408
Suggested statutory form under Neb. Rev. Stat. § 30-3408. Execution under § 30-3404: two adult witnesses or a notary public.
I, ____________________________________ (your name), name the following person as my attorney in fact for health care:
Name: __________________________________________________
Address: ________________________________________________
Telephone number: ____________________________________
SUCCESSOR ATTORNEY IN FACT FOR HEALTH CARE
If my attorney in fact named above is not reasonably available, or is unable or unwilling to serve, I appoint the following person as my successor attorney in fact for health care:
Name: __________________________________________________
Address: ________________________________________________
Telephone number: ____________________________________
I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care.
I direct that my attorney in fact comply with the following instructions or limitations:
______________________________________________________________
______________________________________________________________
______________________________________________________________
I direct that my attorney in fact comply with the following instructions on life-sustaining treatment: (optional)
______________________________________________________________
______________________________________________________________
______________________________________________________________
I direct that my attorney in fact comply with the following instructions on artificially administered nutrition and hydration: (optional)
______________________________________________________________
______________________________________________________________
______________________________________________________________
I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN.
__________________________________________
SIGNATURE OF PERSON MAKING DESIGNATION
Date: ______________________
Do not sign this form until you are in the presence of either two qualified adult witnesses or a notary public. (Neb. Rev. Stat. § 30-3404.)
DECLARATION OF WITNESSES
We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal's attending physician is the person appointed as attorney in fact by this document.
Witness note (Neb. Rev. Stat. § 30-3405). A witness may not be the principal's spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, attending physician, mental health treatment team member, romantic or dating partner, or attorney in fact, or an employee of a life or health insurance provider for the principal. No more than one witness may be an administrator or employee of a health care provider who is caring for or treating the principal.
Witness 1
________________________________________
SIGNATURE OF WITNESS / DATE
Printed name: ________________________________________
Witness 2
________________________________________
SIGNATURE OF WITNESS / DATE
Printed name: ________________________________________
OR
NOTARY ACKNOWLEDGMENT
Use this path instead of the two-witness path. The notary may not be the attorney in fact or successor attorney in fact. (Neb. Rev. Stat. § 30-3404.)
State of Nebraska,
County of ____________________________.
On this ________ day of __________________, 20______, before me, ____________________________,
a notary public in and for __________________ County, personally came ____________________________,
personally to me known to be the identical person whose name is affixed to the above power of attorney for health care as principal, and I declare that he or she appears in sound mind and not under duress or undue influence, that he or she acknowledges the execution of the same to be his or her voluntary act and deed, and that I am not the attorney in fact or successor attorney in fact designated by this power of attorney for health care.
Witness my hand and notarial seal at ______________________________ in such county the day and year last above written.
________________________________________
SIGNATURE OF NOTARY PUBLIC
Printed name: ________________________________________
My commission expires: ____________________________
Notarial Seal:
Attorney in fact note (Neb. Rev. Stat. § 30-3406). The attending physician or a member of the principal's mental health treatment team, certain unrelated employees of the attending physician or treatment team, certain unrelated owners, operators, or employees of a treating health care provider, and a person unrelated to the principal who is already serving as attorney in fact for ten or more principals may not serve as attorney in fact.
Legal currency, verified
This Nebraska power of attorney for health care lets you name an attorney in fact to make health care decisions when you are determined to be incapable of making your own. It tracks the statutory form in Neb. Rev. Stat. § 30-3408.
Verified August 2026 against Neb. Rev. Stat. §§ 30-3401 to 30-3432 on the Nebraska Legislature site. Section 30-3408 supplies a form that may be used. A power of attorney for health care must comply with § 30-3404. Sources include Laws 1992, LB 696 through Laws 2020, LB 247, and later definition updates including the current adult age of eighteen in § 30-3402.
The instrument must be in writing, identify you and your attorney in fact (and any successor), specifically authorize health care decisions if you become incapable, show the date of execution, and be completed with either two adult witnesses or a notary public who is not the attorney in fact or successor. (Neb. Rev. Stat. § 30-3404.) Witnesses may not be your spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, attending physician, mental health treatment team member, romantic or dating partner, or attorney in fact, or an employee of your life or health insurer. No more than one witness may be an administrator or employee of a health care provider who is caring for or treating you. (Neb. Rev. Stat. § 30-3405.)
Primary and successor attorney-in-fact designation with contact fields, optional instructions and limitations, optional life-sustaining treatment directions, optional artificially administered nutrition and hydration directions, the statutory acknowledgment block, and stacked two-witness and notary execution paths. Informational notes summarize witness and attorney-in-fact disqualifications under §§ 30-3405 and 30-3406.
Editable Word and true fillable PDF of the complete Nebraska power of attorney for health care. Customer support and lifetime update access are included with your purchase. A completed sample PDF is available separately as a filled-in reference.
This form is not legal advice. Consider speaking with a Nebraska licensed attorney about your situation.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
Neb. Rev. Stat. § 30-3408 supplies a form that may be used. This packet is designed to track that statutory form and the execution rules in § 30-3404. It is not a government publication.
Sign and date the form in the presence of either two qualified adult witnesses or a notary public who is not your attorney in fact or successor. Do not sign until the witnesses or notary are present. (Neb. Rev. Stat. § 30-3404.)
A witness may not be your spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, attending physician, mental health treatment team member, romantic or dating partner, or attorney in fact, or an employee of your life or health insurer. No more than one witness may be an administrator or employee of a health care provider who is caring for or treating you. (Neb. Rev. Stat. § 30-3405.)
Your attorney in fact may make health care decisions for you when you are determined to be incapable of making your own health care decisions under the Nebraska statutes.
No. This form is limited to health care decisions. Use a separate Nebraska durable power of attorney for property and financial matters.
Both contain the same form text. Word is editable and the PDF is fillable before printing. Complete wet signatures after printing.