Realtor HC and POA

Realtor Healthcare and Power of Attorney

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HealthCare Directives and Powers of Attorney for Asset Management (Statutory Form)

Carefully read all instructions to help us properly prepare your documents.

The PURPOSE OF THIS QUESTIONNAIRE is to assist us in accurately preparing your healthcare and asset powers of attorney, and related documents.

The purpose of these documents is to reduce or eliminate legal fees you will pay to attorneys you do not know and to reduce or eliminate Nevada Guardianship Court involvement in your life. Nevada law says your personal assets are responsible to pay the following costs and fees if a guardianship is ordered:

Court costs (Estimate up to $1,000 first year),
Fees paid to your guardian,
Legal fees paid to your guardian's attorney (currently $350 - $500/hour),and
Legal fess paid to a court appointed attorney to protect your interest

All these costs and fees easily add up to tens of thousands of dollars in the first year and several thousands of dollars for all following years. This will likely devastate your savings and retirement to pay legal fees to attorneys to pay his/her children’s private school tuition, and thus not paid for your benefit or family.

The ESTIMATED TIME to complete this questionnaire is 15 minutes.

Below you will be given the opportunity to select up to three (3) people to serve as your healthcare agent and three (3) people to serve as your financial agents. An “Agent” is/are the person(s) you want to decide matters for you when you cannot while you are living. Do not feel obligated to choose all three (3) for each type of agent. Some people simply do not have enough people to choose from to fill all slots. If you only have one person to serve as your healthcare and financial agent, then so be it.

Documents we will draft for you are:

Directive to Physician (aka Living Will)
Durable Power of Attorney for Healthcare
HIPAA Authorization
Agreement with Nevada Secretary of State Lock Box
Nomination of Guardian for your Person and Estate
Statutory Form Power of Attorney for Asset Management

What You need to have before you start this questionnaire.

You will need the following information for input and responding to questions below:

Your Driver’s License.
Your current Address, City, State, Zip Code, Telephone Number, Birth Date, and Email Address. If different from your driver’s license, provide updated information.
Your First, Second and Third Healthcare Agents - Names, Addresses, Telephone Numbers, Email Addresses and relationship to you.
Your First, Second and third Financial Agents - Names, Addresses, Telephone Numbers, Email Addresses and relationship to you.

For married individuals: each spouse will have to separately complete this questionnaire, which means after the first spouse submits the questionnaire, please close out of the browser and then once again navigate to the website for the other spouse to complete and submit their questionnaire.

The Following Questions are about you.

Below type your full, middle, last and address as shown on your drivers license below.

You, by inputting information requested below, is your agreement we are to assist you in drafting Healthcare and Asset Powers of Attorney, HIPAA release, and Nevada Guardianship Nomination and Agreement to digitally store all of your healthcare documents for our fixed fee.*

I Accept

Married couples will each have to input individual information and pay separately.*

I understand the above statement

Your Name

First Middle Last Suffix

Your Address

Street Address City State / Province / Region ZIP / Postal Code Country

Your Email

Enter Email Confirm Email

Your Phone Number (XXX) XXX-XXXX

Your Date of Birth

Month

Day

Year

Last 4 digits of your Social Security Number

**The Nevada Secretary of State requests this information to catalogue your healthcare documents filed in the Living Will Lockbox.

What is your Gender?

Are you a female who can still give birth to children?

In the future, if you are: 1) pregnant, and 2) your condition is terminal and irreversible, would you like to keep your body alive to for your child?

Selecting Healthcare Agent(s) to decide health care matters for you when you cannot

A Healthcare Agent is someone who you select to decide personal healthcare matters for you when you cannot because of age, illness or injury. The individual you select to be your healthcare agent will also be nominated to be your guardian for your person (someone who will decide healthcare matters for you such what doctors you see, assist with medication, where you will live, etc.).

First Healthcare Agent's Name

First Last Suffix

First Healthcare Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

First Healthcare Agent's Email

First Healthcare Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

Do you want this person to also be your First Financial Agent?

**If you choose this option, you won’t need to enter information for your First Financial Agent. The details provided above will automatically apply to your First Financial Agent if you select “Yes.”

Do you have another individual you want to be your healthcare agent if your First Healthcare Agent refuses to serve, or otherwise cannot serve?

Second Healthcare Agent's Name

First Last Suffix

Second Healthcare Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Second Healthcare Agent's Email

Second Healthcare Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

Do you want this person to also be your Second Financial Agent?

**If you choose this option, you won’t need to enter information for your Second Financial Agent. The details provided above will automatically apply to your Second Financial Agent if you select “Yes.”

Do you have another individual you want to be your healthcare agent if your Second Healthcare Agent refuses to serve, or otherwise cannot serve?

Third Healthcare Agent's Name

First Last Suffix

Third Healthcare Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Third Healthcare Agent's Email

Third Healthcare Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

Do you want this person to also be your Third Financial Agent?

**If you choose this option, you won’t need to enter information for your Third Financial Agent. The details provided above will automatically apply to your Third Financial Agent if you select “Yes.”

Financial Agent's Information

A Financial Agent is someone who you select to decide financial matters for you when you cannot because of age, illness or injury. The individual you select to be your financial agent will also be nominated to be your guardian for your estate. "Estate" is the term used in the Nevada Revised Statutes that essentially means all property you own that is not titled in a trust of any kind. In other words, all property titled in your name, including property you hold joint title with another person such as your spouse is "estate" property.

First Financial Agent's Name

First Last Suffix

First Financial Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

First Financial Agent's Email

First Financial Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

Do you have another individual you want to be your financial agent if your First Financial Agent refuses to serve, or otherwise cannot serve?

Second Financial Agent's Name

First Last Suffix

Second Financial Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Second Financial Agent's Email

Second Financial Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

Do you have another individual you want to be your financial agent if your Second Financial Agent refuses to serve, or otherwise cannot serve?

Third Financial Agent's Name

First Last Suffix

Third Financial Agent's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Third Financial Agent's Email

Third Financial Agent's Phone

What is this person's relationship to you?

Please describe your relationship with this person.

HIPPA Release Information

This section describes a HIPAA release form.The Health Insurance Portability and Accountability Act (federal law aka HIPAA) provides you may allow named persons to inquire with your healthcare providers on your health status, prognosis, and other related matters. The privilege of an individual you name to inquire about your healthcare DOES NOT PROVIDE authority to decide healthcare matters and provide direction to healthcare providers. The authority to provide direction to healthcare providers are left to your agent named in a Healthcare Power of Attorney (a completely different document).Under the Unites States Constitution, states are to recognize other states documents, judgements, etc. so long as such document, judgement do not violate another state's public policy. Each state in the Union has created their own healthcare power of attorney (Healthcare POA). Frequently, but not always, states have passed their own HIPAA equivalent language and waivers of release of information. One state's waiver language may not meet public policy for another state.As such, since most persons travel among the states, and a real possibility of a state (not Nevada) may not recognize the Nevada healthcare waiver language, we draft for you a HIPAA release language that fall directly out of the United States Code. Under the Constitution, US statutes and laws supersede state statutes and laws when they conflict. Thus the HIPAA waiver will be sufficient to cover a state other than Nevada. The HIPAA waiver is an important form to follow you though out all 50 states to ensure your designated Healthcare POA can decide matters for you incases of when you are in need of medical assistance.This is in addition to your Healthcare Agents which will be the first listed. Please select Yes to add any additional person(s) and No to move on to the next section.

How many people do you want to list on your HIPPA Release Form?

Type the full name of the first person you want to be on your HIPPA Release form

First Last

(Please do not include your Healthcare or Financial agents, they are all ready included)

Type the full name of the second person you want to be on your HIPPA Release form

First Last

(Please do not include your Healthcare or Financial agents, they are all ready included)

Type the full name of the third person you want to be on your HIPPA Release form

First Last

(Please do not include your Healthcare or Financial agents, they are all ready included)

Type the full name of the fourth person you want to be on your HIPPA Release form

First Last

(Please do not include your Healthcare or Financial agents, they are all ready included)

Type the full name of the fifth person you want to be on your HIPPA Release form

First Last

(Please do not include your Healthcare or Financial agents, they are all ready included)

Did you have any issues filling this out?*

This helps us make sure every step is as easy as possible for our clients. Thank you!

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