Durable Power of Attorney for Health Care - kansas - Edit, Fill, Sign Online

STATE OF KANSAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE

DECISIONS GENERAL STATEMENT OF AUTHORITY GRANTED

I,

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, designate and appoint:

Name

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Address:

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Telephone Number:

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to be my agent for health care decisions and pursuant to the language stated below, on my behalf

to:

(1) Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to

maintain, diagnose or treat a physical or mental condition, and to make decisions about organ

donation, autopsy and disposition of the body;

(2) make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment

facility, hospice, nursing home or similar institution; to employ or discharge health care personnel

to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person

who is licensed, certified or otherwise authorized or permitted by the laws of this state to

administer health care as the agent shall deem necessary for my physical, mental and emotional

well being; and

(3) request, receive and review any information, verbal or written, regarding my personal affairs

or physical or mental health including medical and hospital records and to execute any releases of

other documents that may be required in order to obtain such information.

In exercising the grant of authority set forth above my agent for health care decisions shall:

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(Here may be inserted any special instructions or statement of the principal's desires to be

followed by the agent in exercising the authority granted).

LIMITATIONS OF AUTHORITY

(1) The powers of the agent herein shall be limited to the extent set out in writing in this

durable power of attorney for health care decisions, and shall not include the power to revoke or

invalidate any previously existing declaration made in accordance with the natural death act.

(2) The agent shall be prohibited from authorizing consent for the following items:

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(3) This durable power of attorney for health care decisions shall be subject to the additional

following limitations:

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EFFECTIVE TIME

This power of attorney for health care decisions shall become effective (immediately and

shall not be affected by my subsequent disability or incapacity or upon the occurrence of my

disability or incapacity).

REVOCATION

Any durable power of attorney for health care decisions I have previously made is hereby

revoked.

(This durable power of attorney for health care decisions shall be revoked by an instrument in

writing executed, witnessed or acknowledged in the same manner as required herein or set out

another manner of revocation, if desired.)

EXECUTION

Executed this ____________, at _________________________, Kansas.

________________________ Principal.

This document must be: (1) Witnessed by two individuals of lawful age who are not the

agent, not related to the principal by blood, marriage or adoption, not entitled to any portion of

principal's estate and not financially responsible for principal's health care; OR (2) acknowledged

by a notary public.

______________________________ __________________________________

Witness Witness

______________________________ __________________________________

Address Address

(OR)

STATE OF ________________________)

SS.

COUNTY OF _______________________)

This instrument was acknowledged before me on __________ by ______________________.

(date) (name of person)

__________________________________ (Signature of notary public)

(Seal, if any)

My appointment expires:__________________________

Fillable Printable Durable Power of Attorney for Health Care - kansas

Fillable Printable Durable Power of Attorney for Health Care - kansas

Durable Power of Attorney for Health Care - kansas