Fillable Printable Durable Power of Attorney for Health Care Example - Kansas

Durable Power of Attorney for Health Care Example - Kansas

uT R Ty R T

T T S uT R Ty R T

S T S T SP R

DURABLE

POWER

ATTORNEY

FOR

HEALTHCARE

DECISIONS

DECI ION O NAME OMEONE O EAK FO ME

(your name) _______________________________________________________________ (date of birth) _________________

appoint the following person(s) to

make healthcare decisions for me when I am unable to make or communicate my own wishes:

agent may not be the treating healthcare provider, an employee of the treating healthcare provider, or an employee, owner,

director or officer of a facility, unless that person is a relative or is bound to you by common vows to a religious life.

PLEASE PRINT:

Name of Agent:_______________________________________________________________ _______________________ ______________________

agent’s address: ___________________________________________________________City________________________State/Zip ________________

Name of First Alternate Agent: _________________________________________________ _______________________ ______________________

agent’s address: ___________________________________________________________City________________________State/Zip ________________

Name of econd Alternate Agent: _______________________________________________ _______________________ ______________________

agent’s address: ___________________________________________________________City________________________State/Zip ________________

Telephone

his power of attorney for healthcare decisions shall become effective when I am unable to make decisions or unable to communicate

my wishes regarding healthcare. his power of attorney for healthcare decisions shall not be affected by my subsequent disability or in-

capacity. Any durable power of attorney for healthcare decisions I have previously made is hereby revoked.

A hO I G AN ED

My healthcare agent may:

1. Consent, refuse consent, or withdraw consent to any care,

treatment, service or procedure to maintain, diagnose or

treat a physical or mental condition;

2. Make all arrangements for me at any hospital, treatment

facility, hospice, nursing home or similar institution;

3. employ or discharge healthcare personnel including physi-

cians, psychiatrists, dentists, nurses, therapists or other

persons who provide treatment for me;

4. Request, receive and review any information, spoken or

written, regarding my personal affairs or physical or men-

tal health including medical and hospital records, and exe-

cute any releases or other documents that may be required

in order to obtain such information; and

5. Make decisions about organ and tissue donations,

autopsy and the disposition of my body.

My agent shall authorize consent for the following special

instructions:

■

I wish to be a donor for organs and tissues.

■

I have attached information about treatment choices I wish

to have honored by my agent. page(s) attached.

LIMI A ION ON A hO I G AN ED

My healthcare agent may not:

1. exceed the powers set out in writing in this document;

2. Revoke any existing Living Will Declaration I may have.

X __________________________________________

signature date

Notary Seal:

Notary ublic:

STaTe Of COuNTY Of

This instrument was acknowledged before me this day of (month, year)

Signature of Notary

itnesses: (witnesses may not be the agent or a relative, or beneficiary of the principal)

X ___________________________________________________ Date: _________________________________________________

(Signature)

X ___________________________________________________ Date: _________________________________________________

(Signature)