SB 121 — Revises provisions relating to fiduciaries. (BDR 13-99)

I would like my agent to help me decide if I need to see a dentist and help me make decisions about what care or treatmentmy Iagent shouldwill receivesign fromany thenecessary dentist.paperwork..

Once we decide, I would also like my agent willto signbe anyable necessaryto paperwork.see and have copies of all my medical records.

I would also like my agent to be able to see and have copies of all my medical records.

I also understand that - *SB121_R2* – 6 – I can take away this power from my agent at any time, either by telling my agent that he or she is no longer my agent or by putting it in writing.

(insert the name of another person you wish to designate as your alternative - 80th Session (2019) – 6 – agent to make health care decisions for you) as my agent to make health care decisions for me as authorized in this document.

(insert name of principal), I agree that a physician, health care facility or other provider of health care, acting in good faith, may rely on this power of attorney for health care and the signatures herein, and I of understand that pursuant to NRS 162A.815, a physician, health care facility or other provider of health care that in good faith accepts an acknowledged power of attorney foratfor in health care is not subject to civil or criminal liability or discipline for unprofessional conduct for giving effect to a declaration contained within the power of attorney for health care or for following the direction of an agent named in the power of attorney for health care.

I have a duty to act in a manner consistent with the desiresdocument ofor otherwise made known by ..........

(insert namenamein this of principal)principal), asor statedif inhis thisor documenther ordesires otherwiseare madeunknown, knownto byact ..........in his or her best interest.

(insert name of principal), or if his or her desires are unknown, to act in his or her best interest.

(insert name of principal) revokes this power of attorney at any time, either verbally or in writing, I have a duty to inform any persons who may rely on this document, including, without limitation, treating physicians, hospital staff or other providers of health care, - *SB121_R2* – 7 – that I no longer have the authorities described in this document.

The provisions of NRS 162A.840 prohibit me from being named as an agent to make health care decisions in this document if I am a provider of health care, an employee - 80th Session (2019) – 7 – of the principal’s provider of health care or an operator or employee of a health care facility caring for the principal, unless I am the spouse, legal guardian or next of kin of the principal.

(b)(c) ConvulsivePsychosurgery;atment; treatment;

(c) Psychosurgery;

or (h) Any other care or treatment to which the principal prohibits the agent from consenting in this document.ipaldocument. 5.

End-of-life5. decisions must be made according to the the attached addendum.

IfEnd-of-life his or her wishes are not known,ated in such decisions must be made inaccording consultationto with the principal’swishes treatingof physicians...........

(insert name of principal), as designated in the attached addendum.

If his or her wishes are not known, such decisions must be made in consultation with the principal’s treating physicians.

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Relationship to principal:

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(THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO YOU KNOW AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) - *SB121_R2*80th Session (2019) – 8 – CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC 4 (You may use acknowledgment before a notary public instead of the statement of witnesses.) 7 State of Nevada } }ss.

(Signature) STATEMENT OF WITNESSES (If you choose to use witnesses instead of having this document notarized, you must use two qualified adult witnesses.

(2) a provider of (4) the operator of a health carecare; facility;

(3) an employee of a provider of health care;

(4) the operator of a health care facility;

At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

- 80th Session (2019) – 9 – Signature:

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- *SB121_R2* – 9 – Signature:

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5 (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) 8 I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

........................Address:...........................Address:

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You should retain an executed copy of this shoulddocument beand availablegive soone a copy may be given to your providersagent. of health care.

The power of attorney should be available so a copy may be given to your providers of health care.

You do not have to complete this form, but if you do, your agent must do as you ask if you cannot speak for yourself.) - 80th Session (2019) – 10 – ....................

- *SB121_R2* – 10 – If you are not able to talk to ....................

5 Here are your choices.

8 1.

YES NO (YOU MUST DADECISIONSDATDECISIONS ADDENDUM)D-OF-LIFEADDENDUM)-OF-LIFE I sign my name to this End-of-Life Decisions Addendum on ..............

OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) - 80th Session (2019) – 11 – CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC (You may use acknowledgment before a notary public instead of the statement of witnesses.) - *SB121_R2* – 11 – State of Nevada } }ss.

County of ........................} 5 On this ..........

At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.) set out I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this End-of-Life Decisions Addendum in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by the power of attorney for health care and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

- 80th Session (2019) – 12 – Signature:

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- *SB121_R2* – 12 – (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) 4 I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

........................Address:...........................Address:

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The End-of-Life Decisions Addendum should be available so a copy may be givenSec. to your providers of health care.

Sec.2.en tNRS 162A.460 is hereby amended to read as follows:

162A.460 1.

Except as otherwise provided in NRS 162A.450, if a power of attorney grants to an agent authority to do all acts that a principal could do or refers to general authority or cites a section of NRS 162A.200 to 162A.660, inclusive, in which the authority is described, the agent has the general authority described in NRS 162A.200 to 162A.660, inclusive.

NRS 162A.460 is hereby amended to read as follows:

162A.450, if a power of attorney grants to an agent authority to do all acts that a principal could do or refers to general authority or the authority is described, the agent has the general authorityh described in NRS 162A.200 to 162A.660, inclusive.

2.

- 80th Session (2019) – 13 – 4.

An act performed by an agent pursuant to a power of attorney has the same effect and inures to the benefit of and binds the principal and the principal’s successors in interest as if thethes principal had performed the act.

- *SB121_R2* – 13 – 7.

BEFORE EXECUTING THIS DOCUMENT,IMPORTANT YOUFACTS:YOU SHOULD KNOW THESE IMPORTANT1. FACTS:

1.

YOUR AGENT WILL BE ABLE TO MAKE DECISIONS AND ACT WITH RESPECT TO YOUR PROPERTY (INCLUDING YOUR MONEY) WHETHER OR NOT YOU ARE ABLE TO ACT FOR YOURSELF.

EFFECTIVE2. IMMEDIATELY UNLESS YOU STATEY BECOMES OTHERWISE IN THE SPECIAL INSTRUCTIONS.

3.THIS POWER OF ATTORNEY BECOMES EFFECTIVE IMMEDIATELY UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.

- 80th Session (2019) – 14 – 3.

- *SB121_R2* – 14 – 6.

THIS FORM PROVIDES FOR DESIGNATION OF ONE AGENT.AGENT YOU MAY NAME A CO-AGENT IN THE SPECIAL INSTRUCTIONS.

IF YOU WISH TO NAME MORE THAN ONE AGENT YOU MAY NAME A CO-AGENT IN THE SPECIAL INSTRUCTIONS.

- 80th Session (2019) – 15 – 1.

as my agent to make decisions for me and in my name, place andpowers steadas andauthorized forin mythis usedocument.nd and benefit and to exercise the powers2. as authorized in this document.

2.

Also, if the agent designated in paragraph 1 is your spouse, his or her designation as your agent is automatically revoked by law if your marriage is dissolved.) If my agent is unable or unwilling to act for me, then I designate the following person(s) to serve as my agent as - *SB121_R2* – 15 – authorized in this document, such person(s) to serve in the order listed below:

4 A.

9 B.

Second Alternative Agent Name:................................................................

If, after execution of this Power of Attorney, proceedings seeking an adjudication of incapacity are initiated either for my estate or my person, I hereby nominate as my guardian or - 80th Session (2019) – 16 – conservator for consideration by the court my agent herein named, in the order named.

5.

GRANT OF GENERAL AUTHORITY.

If you wish to grant general authority over all of the subjects you may initial “All Preceding Subjects” instead of initialing each subject.) [.....] Real Property [.....] Tangible Personal Property [.....] Stocks and Bonds [.....] Commodities and Options [.....] Banks and Other Financial Institutions [.....] Safe Deposit Boxes [.....] Operation of Entity or Business [.....] Insurance and Annuities [.....] Estates, Trusts and Other Beneficial Interests [.....] Legal Affairs, Claims and Litigation [.....] Personal Maintenance [.....] Benefits from Governmental Programs or Civil or Military Service - *SB121_R2* – 16 – [.....] Retirement Plans [.....] Taxes [.....] All Preceding Subjects 5 6.

My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authorityauthorityacts listed below:

INITIAL ONLY the specific authority you WANT to give your agent.) [.....] Create, amend, revoke or terminate an inter vivos, family, living, irrevocable or revocable trust [.....] Make a gift, subject to the limitations of NRS and any special instructions in this Power of Attorney - 80th Session (2019) – 17 – [.....] Create or change rights of survivorship [.....] Create or change a beneficiary designation [.....] Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan [.....] Exercise fiduciary powers that the principal has authority to delegate power[.....] ofDisclaim appointmentrefuseor refuse an interest in property, including a power of appointment 7.

Except as otherwise expressly provided in this Power of Attorney, the authority of a principal to act on his or her own behalf continues after executing this Power of Attorney - *SB121_R2* – 17 – and any decision or instruction communicated by the principal supersedes any inconsistent decision or instruction communicated by an agent appointed pursuant to this PowerPowe[9.] of10. Attorney.

[9.] 10.

(INITIAL the clause(s) that applies.) 8 [.....] DURABLE.

It is my intention and direction that my designated agent, and any person or entity that my designated agent may transact business with on my behalf, may rely on a written medical opinion issued by a licensed medical doctor stating that I am disabled or incapacitated, and incapable of managing my affairs, and that said medical opinion shall establish whether or not I am under a disability for the purpose of establishing the authority of my - 80th Session (2019) – 18 – designated agent to act in accordance with this Power of Attorney.

[.....] I wish to have this Power of Attorney end on the following date:

..........e this Power of Attorney end on the [10.] 11.

[10.] 11.

Third parties may rely upon the validity of this Power of Attorney or a copy and the representations of my agent as to all matters relating to any power granted to my agent, and no person or agency who relies upon the representation of my agent, or the authority granted by my agent, shall incur any liability to me or my estate as a result of permitting my agent to exercise any power unless a third party knows or has reason to know this Power of Attorney has terminated or is invalid.

I agree to, authorize and allow full release of information, by any government agency, business, creditor or third party who may have information pertaining to my assets or income, to my agent named herein.

- *SB121_R2* – 18 – I sign my name to this Power of Attorney on ..............

(Signature) 6 CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC 9 (You may use acknowledgment before a notary public instead of the statement of witnesses.) State of Nevada } }ss.

County of ........................} - 80th Session (2019) – 19 – On this ..........

[I declare under penalty of perjury that the person whose name is ascribed to this instrument appears to influence.]be of sound mind and under no duress, fraud or undue influence.] NOTARY SEAL (Signature........................................... of Notary Public)................

(Signature of Notary Public) IMPORTANT INFORMATION FOR AGENT 1.

and (d) Disclose your identity as an agent whenever you act for the principal by writing or printing the name of the - *SB121_R2* – 19 – principal and signing your own name as “agent” in thethethe following manner:

(e) Cooperate with any person that has authority to make health care decisions for the principal to do what you know - 80th Session (2019) – 20 – the principal reasonably expects or, if you do not know the principal’s expectations, to act in the principal’s best interest;

You must stop acting on behalf of the principal if you learn of any event that terminates this Power of Attorney or your authority under this or your authority to act under a Power of Attorney.Attorney include:y (a) Death of the principal;

Events(b) thatThe terminateprincipal’s arevocation of the Power of Attorney or (a)your Deathauthority; of the principal;

(c) The occurrence of a termination event stated in the Power of AttorneyAttorney; include:

(b) The principal’s revocation of the Power of Attorney or you(c) The occurrence of a termination event stated in the Power of Attorney;

162A.700 NRS 162A.700 to 162A.865, inclusive, and section 1.5 of this act apply to any power of attorney containing thetheion authority to make health care decisions.

- *SB121_R2* – 20 – Sec.

- 80th Session (2019) – 21 – DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT.

THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT THE POWER TO MAKE SUBJECTHEALTH TOCARE ANY LIMITATIONS OR STATEMENT OFIS YOUR DESIRES THAT YOU INCLUDE IN THIS DECISIONS FOR YOUYOU. MAY INCLUDE CONSENT,E REFUSAL OF CONSENT OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE OR PROCEDURE TO MAINTAIN, DIAGNOSE OR TREAT A PHYSICAL OR MENTAL CONDITION.

YOUTHIS MAYPOWER STATEIS INSUBJECT THISTO DOCUMENT ANY TYPESLIMITATIONS OFOR TREATMENTSTATEMENT OROF PLACEMENTSYOUR DESIRES THAT YOU DOINCLUDE NOTIN DESIRE.THIS DOCUMENT.

THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL OF CONSENT OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE OR PHYSICAL OR MENTAL CONDITION.

YOU MAYEAT A STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.

3.3.EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THE POWER OF THE PERSON YOU DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YOU ALIVE.

EXCEPT4.UNLESS AS YOU OTHERWISE SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THETHIS POWER OFWILL EXIST INDEFINITELY FROM THE PERSONDATE YOU DESIGNATEEXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR YOUYOURSELF, MAYTHIS INCLUDEPOWER THEWILL POWERCONTINUE TO CONSENTEXIST UNTIL THE TIME - *SB121_R2*80th –Session 21(2019) – TO22 YOUR– DOCTORWHEN NOTYOU GIVINGBECOME TREATMENTABLE ORTO STOPPINGMAKE TREATMENTHEALTH WHICHCARE WOULDDECISIONS KEEPFOR YOUYOURSELF. ALIVE.

4.5.NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION.

UNLESS YOU SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THIS POWER WILL EXIST INDEFINITELY FROM THE DATE YOU EXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU BECOME ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.

5.

NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION.

6.6.YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THAT PERSON OF THE REVOCATION ORALLY OR IN WRITING.

YOU7.YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENTAUTHORITY OFGRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTHTHE CARETREATING PHYSICIAN, HOSPITAL OR OTHERG PROVIDER OF THEHEALTH REVOCATIONCARE ORALLY OR IN WRITING.SONWRITING. 7.

YOU HAVE THE RIGHT TO REVOKE THE DESIGNATED INANTHIS DOCUMENTTHE TO PEMAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL OR OTHER PROVIDER OF HEALTH CARE ORALLY OR IN WRITING.

10.10.IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

IF1.DESIGNATION THEREOF ISHEALTH ANYTHINGCARE INAGENT. THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

- *SB121_R2* – 22 – 1.

DESIGNATION OF HEALTH CARE AGENT.

5 Name:

9- 80th Session (2019) – 23 – as my agent to make health care decisions for me as authorized in this document.

(3) an operator of a health care facility;facility.)or (4) an employee of an operator of a health care 2.

or (4) an employee of an operator of a health care facility.) 2.

By this document I intend to create a durable power of attorney by appointing the person designated above to make behealth affectedcare bydecisions myfor subsequentme. incapacity.

This power of attorney shall not 3.be affected by my subsequent incapacity.

GENERAL3. STATEMENT OF AUTHORITY GRAIn the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent named above full power and authority:

GENERAL STATEMENT OF AUTHORITY GRANTED.

In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent named above full power and authority:

to execute on my behalf any releases or other documents that may be required to obtain medical care and/or medical and hospital records, EXCEPT any power to enter into any arbitration agreements or execute any arbitration clauses in connection with admission to any health care facility including any skilled nursing facility;

- *SB121_R2* – 23 – 4.

If there are any other types of treatment or placement that you do not want your agent’s authority to give consent for or other restrictions you wish to - 80th Session (2019) – 24 – place on his or her agent’s authority, you should list them in the space below.

If you do not write any limitations, your agent will have the broad powers to make health care decisions on your behalf which are set forth in paragraph 3, exceptexcIn to the extent that there are limits provided by law.) In exercising the authority under this durable power ofof.) attorney for health care, the authority of my agent is subject to the following special provisions and limitations:

If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent will continue to exist until thefor timemyself.en when I become able to make health care decisions for(IF myself.APPLICABLE) I wish to have this power of attorney end on the following date:

(IF APPLICABLE) I wish to have this power of attorney end on the following date:

If you wish to indicate your desires, you may INITIAL the statement or statements that reflect your desires and/or write your own statements in the space below.) - *SB121_R2*80th Session (2019) – 2425 – (If the statement reflects your desires, initial the box next to the statement.) 6 1.

I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the cost of the procedures.procedures., [........................] 2.

[........................] 2.

If I have an incurable or terminal condition or illness and no reasonable hope of long-term thatveryrecovery life-sustainingdesioror prolongingsurvival, treatmentsI notdesire bethat provisionslife-sustaining ofor NRSprolonging 449A.400treatments tozenot 449A.481,be inclusive,used. if this subparagraph is initialed.) [........................] 4.

(Also should utilize provisions of NRS 449A.400 to subparagraph is initialed.)s [........................] 4.

[........................] - 80th Session (2019) – 26 – 5.

My agent is to consider the relief of suffering, the - *SB121_R2* – 25 – preservation or restoration of functioning, and the quality as well as the extent of the possible extension of my life.

[........................] 6 (If you wish to change your answer, you may do so by drawing an “X” through the answer you do not want, and circling the answer you prefer.) Other or Additional Statements of Desires:

Also, if the agent designated in paragraph 1 is your spouse, his or her designation as your agent is automatically revoked by law if youIf the person designated in paragraph 1 as my agent is unable to make health care decisions for me, then I designate the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:

- 80th Session (2019) – 27 – B.

- *SB121_R2* – 26 – 9.

If my designated agent is my spouse or is one of my children, then I waive any conflict of interest in carrying out the provisions of this Durable Power of Attorney for Health Care that said spouse or child may have by reason of the fact that he or she may be a beneficiary of my estate.

If, after execution of this Durable Power of Attorney for Health Care, proceedings seeking an adjudication of incapacity are initiated either for my estate or my person, I hereby nominate as my guardian or conservator for consideration by the court my agent herein named, in the orderorde12.amRELEASE named.OF INFORMATION.

12.I agree to, authorize and allow full release of information by any government agency, medical provider, business, creditor or third party who may have information pertaining to my health care, to my agent named herein, pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended, and applicable regulations.

RELEASE- 80th Session (2019) – 28 – (YOU MUST DATE AND SIGN THIS POWER OF INFORMATION.ATTORNEY) I sign my name to this Durable Power of Attorney for .........................

by(state)te) anyat government.............................. agency, medical provider, business,formation creditor or third party who may have information pertaining Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended, and applicable regulations.

(YOU(city), MUST........................................... DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Durable Power of Attorney for Health Care on ..............

(date)(Signature) at(THIS ..............................POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC (You may use acknowledgment before a notary public instead of the statement of witnesses.) State of Nevada } }ss.

(city), .........................

(state) ...........................................

(Signature) (THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR - *SB121_R2* – 27 – ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) 4 CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC 7 (You may use acknowledgment before a notary public instead of the statement of witnesses.) State of Nevada } }ss.

[I declare under penalty of perjury that the person whose name is ascribed to this instrument appears to beinfluence.] of sound mind and under no duress, fraud or undue influence.] NOTARY SEAL ...........................................

(Signature of Notary Public) - 80th Session (2019) – 29 – STATEMENT OF WITNESSES (You should carefully read and follow this witnessing procedure.

This document will not be valid unless you complywitnesses withinstead theof witnessinghaving procedure.this document notarized, youe must use two qualified adult witnesses.

If you elect to use witnesses instead of having this document notarized, you must use two qualified adult witnesses.

At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no - *SB121_R2* – 28 – duress, fraud or undue influence, that I am not the person appointed as agent by this document and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

7 Signature:

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(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the to best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

- 80th Session (2019) – 30 – Signature:

........................Address:..........................Address:

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COPIES:document and give one to your agent.

You should retain an executed copy of this document and give one to your agent.

- *SB121_R2* – 29 – DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS 4 My name is....................

I understandundIf whatI thisam means.sick or hurt, my agent should take me to the doctor.

If I am sick or hurt, my agent should take me to the doctor.

If I go to the hospital, I would like the people who able- to80th communicate,Session I(2019) would– like31 the– doctorwork at the hospital to speaktry withvery mehard andto my agent about what care orfor treatment I being said about me.

AfterIf weI am able to communicate, I would like the doctor at the hospital to speak with theme doctor,and my agent about what care or treatment I wouldshould receive, even if I am unable to understand what is like my agent to help me decide what care or treatment IIould should receive.

I understand that my agent cannot make me receive any care or treatment that I do not want.

I also understand that I can take away this power from my agent at any time, either - *SB121_R2* – 30 – by telling my agent that he or she is no longer my agent or by putting it in writing.

9 (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Durable Power of Attorney for Health Care on ..............

(Signature) - 80th Session (2019) – 32 – AGENT SIGNATURE As agent for..........

(insert name of principal), I agree that a physician, health care facility or other provider of health care, acting in good faith, may rely on this power of attorney for health care and the signatures herein, and I understand that pursuant to NRS 162A.815, a physician, health care facility or other provider of health care that in good faith accepts an acknowledged power of attorney for health care is not subject conduct for giving effect to a declaration contained within the power of attorney for health care or for following the direction of an agent named in the power of attorney for health care.

The provisions of NRS 162A.840 prohibit me from being named as an agent to make health care decisions in this - *SB121_R2* – 31 – document if I am a provider of health care, an employee of the principal’s provider of health care or an operator or employee of a health care facility caring for the principal, unless I am the spouse, legal guardian or next of kin of the principal.

- 80th Session (2019) – 33 – (f) Aversive intervention, as it is defined in NRS 449A.203;

................Residence...................Residence Address:

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(THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO YOU KNOW AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC - *SB121_R2* – 32 – (You may use acknowledgment before a notary public instead of the statement of witnesses.) 4 State of Nevada } }ss.

County of......................................} 8 On this..........

[I - 80th Session (2019) – 34 – declare under penalty of perjury that the person whose name is ascribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence.] NOTARY SEAL .........................................

(Signature) STATEMENT OF WITNESSES (Ifdocument notarized, you choosemust to use witnessestwo insteadqualified ofadultis having this witnesses.

(2) a provider of the operator of a health carecare; facility;

(3) an employee of a provider of health care;

(4) the operator of a health care facility;

.................Residence...................Residence Address:

Print Name:

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- *SB121_R2* – 33 – Signature:

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5 (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) 8 I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the - 80th Session (2019) – 35 – estate of the principal upon the death of the principal under a will now existing or by operation of law.

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You should retain an executed copy of this shoulddocument beand availablegive soone a copy may be given to your providersagent. of health care.

The power of attorney should be available so a copy may be given to your providers of health care.

The form for end-of-life decisions of a power of attorney for health care for an adult with an intellectual disability may be substantiallyexecuted in the followingsame form,manner andas mustthe befollowing witnessedform:itnessed or executedEND-OF-LIFE inDECISIONS theADDENDUM sameSTATEMENT mannerOF asDESIRES the(You followingcan, form:but are not required to, state what you want to happen if you get very sick and are not likely to get well.

END-OF-LIFE DECISIONS ADDENDUM STATEMENT OF DESIRES (You can, but are not required to, state what you want to happen if you get very sick and are not likely to get well.

- *SB121_R2* – 34 – If you are not able to talk to....................

5 Here are your choices.

8- 80th Session (2019) – 36 – 1.

I do not want to take medicine or receive treatment if I am very sick and suffering and the medicine or treatment will not help me get better.

YES NO (YOU MUST DATDECISIONSDATE ADDENDUM)-OF-LIFEAND onSIGN THIS END-OF-LIFE DECISIONS ADDENDUM) I sign my name to this End-of-Life Decisions Addendum on ..............

(Signature) (THIS END-OF-LIFE DECISIONS ADDENDUM WILL NOT BE VALID UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO YOU KNOWACKNOWLEDGEO AND WHO ARE PRESENTPRESEYOURHEN WHENYOSIGNATURE YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.) CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC (You may use acknowledgment before a notary public instead of the statement of witnesses.) - *SB121_R2* – 35 – State of Nevada } }ss.

County of......................................} 5- 80th Session (2019) – 37 – On this..........

(2) a provider of the operator of a health carecare; facility;

(3) an employee of a provider of health care;

(4) the operator of a health care facility;

At least one of the witnesses placemust wheremake the witnessesadditional sign.)tiondeclaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this End-of-Life Decisions Addendum in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by the power of attorney for health care and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

.................Residence...................Residence Address:

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.................Residence...................Residence Address:

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- *SB121_R2*80th Session (2019) – 3638 – (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) 4 I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

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status,253.220 assets1. and personal and family history of any protectedl person for whom the public guardian has been appointed as pursuant to chapter 648 of NRS.

InA connection with thee investigator investigation, the public guardian may requireinvestigate the protectedfinancial personstatus, orassets anyand spouse,personal parent,and childfamily orhistory other kindred of theany protected person,person tofor givewhom anythe informationpublic andguardian tohas executebeen andappointed deliveras anyguardian, writtenwithout requestshiring or authorizationsbeing necessarylicensed toas providea theprivate publicinvestigator guardianpursuant with access to records,chapter otherwise648 confidential,of whichNRS. are needed by the public guardian.

In connection with the investigation, the public guardian may require the protected protected person, to give any information and to execute and deliver any written requests or authorizations necessary to provide the public guardian with access to records, otherwise confidential, which are needed by the public guardian.

In a county whose population is less than 100,000, a public guardian may petition a court to investigate the financial status, assets and personal and family history of any [person for whom the public guardian has been appointed as guardian,] potential protected person for whom the public guardian has received a referral from the Aging and Disability Services Division of the Department of - 80th Session (2019) – 39 – Health and Human Services, a law enforcement agency or a court in connection with a criminal or civil matter relating to the - *SB121_R2* – 37 – potential protected person, without hiring or being licensed as a private investigator pursuant to chapter 648 of NRS.

In connection with the investigation, the public guardian may require [any protected person] the potential protected person or any spouse, parent, child or other kindred of the [protected person] potential protected person, to give any information and to execute and deliver any written requests or authorizations necessary to provide the public guardian with access to records, otherwise confidential, which are needed by the public guardian.

The public guardian may obtain information from any public record office of the State or any of its agencies or subdivisions upon request and without payment ofyof any fees.

H~~~~~ 19 - *SB121_R2*80th Session (2019)