- Durable Power of Attorney for Health Care and Living Will
- Health Care Power of Attorney - Maine
- Statutory Short Form Power of Attorney for Health Care - Illinois
- Power of Attorney for Health Care Will to Live Form - Idaho
- Washington Durable Power of Attorney for Health Care
- Health Care Power of Attorney Example - South Carolina
Fillable Printable Durable Power of Attorney for Health Care Example - Kansas
Fillable Printable Durable Power of Attorney for Health Care Example - Kansas
Durable Power of Attorney for Health Care Example - Kansas
uTR Ty RT
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or
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S T S T SPR
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P
W
DURABLE
POWER
OF
ATTORNEY
FOR
HEALTHCARE
DECISIONS
DECI IONONAMEOMEONEOEAKFOME
I,
(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:
NameofAgent:_______________________________________________________________ _______________________ ______________________
agent’s address: ___________________________________________________________City________________________State/Zip ________________
NameofFirstAlternateAgent: _________________________________________________ _______________________ ______________________
agent’s address: ___________________________________________________________City________________________State/Zip ________________
NameofecondAlternateAgent: _______________________________________________ _______________________ ______________________
agent’s address: ___________________________________________________________City________________________State/Zip ________________
Telephone
Telephone
Telephone
Telephone
Telephone
Telephone
hispowerofattorneyforhealthcaredecisionsshallbecomeeffectivewhenIamunabletomakedecisionsorunabletocommunicate
mywishesregardinghealthcare.hispowerofattorneyforhealthcaredecisionsshallnotbeaffectedbymysubsequentdisabilityorin-
capacity.AnydurablepowerofattorneyforhealthcaredecisionsIhavepreviouslymadeisherebyrevoked.
AhOIG ANED
Myhealthcareagentmay:
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.
Myagentshallauthorizeconsentforthefollowingspecial
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 IONON AhOIG ANED
Myhealthcareagentmaynot:
1. exceed the powers set out in writing in this document;
2. Revoke any existing Living Will Declaration I may have.
X __________________________________________
signaturedate
Notary Seal:
Notaryublic:
STaTe Of COuNTY Of
This instrument was acknowledged before me this day of (month, year)
Signature of Notary
or
itnesses:(witnessesmaynotbetheagentorarelative,orbeneficiaryoftheprincipal)
X ___________________________________________________ Date: _________________________________________________
(Signature)
X ___________________________________________________ Date: _________________________________________________
(Signature)
