We can only accept POA forms for students who are 18. If your student is 17, wait until their eighteenth birthday to fill out and submit this form to the Health Center; until then, a staff member will call you for consent to treat if/when your student visits the Health Center.
- Download Nebraska Medicine – UNO Health Center’s Power of Attorney form and print it.
- Fill out the form as follows:
- First line: Parent/guardian’s name
- Second line: Parent/guardian’s city and state of residence
- Third line: Student’s name
- Fourth line: Student’s birth date
- Fifth line: NUID number
- On the last bullet point, the parent/guardian should write the day’s date and print his or her name. Do NOT sign until in the presence of a notary.
- The notary will fill out the bottom portion of the form and will then witness the parent/guardian sign.
- Send the completed, notarized form to the University Health Center
- Fax: 402.554.2387
- Mail: 102 Health & Kinesiology Building, 6001 Dodge ST., Omaha NE 68182
A notary is a person authorized to perform certain legal formalities, especially to draw up or certify contracts, deeds and other documents for use in other jurisdictions. Among their many duties, notaries most often notarize signatures for documents requiring a notarial act.
The signer must be physically present before a notary, prove his/her identity and acknowledge that he/she understands the document and is signing under his/her free will.
Oftentimes, notaries can be found at local banks, courthouses, UPS stores, some airports and—for international students—a local consulate.
If a student under 19 seeks medical care at the Health Center and does not have a Power of Attorney form on file, appointment desk staff in most situations must call parents/guardians at the time of check in to complete additional forms over the phone, which will delay patient care in non-emergent situations.