Kansas Medical Power of Attorney Form
In order to allow a person to make decisions related to your health on your behalf in the State of Kansas, the following form has to be completed and submitted.
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STATE OF KANSAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS GENERAL STATEMENT OF AUTHORITY GRANTED I, -------------------------------------------------------------------------------- , designate and appoint: Name -------------------------------------------------------------------------------- Address: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Telephone Number: -------------------------------------------------------------------------------- to be my agent for health care decisions and pur suant 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 institutio n; 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 fo rth above my agent for health care decisions shall: --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- (Here may be inserted any special instructions or statement of the principal's desires to be followed by the agent in exerci sing 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 decisi ons, 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: --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- (3) This durable power of attorney for h ealth care decisions shall be subject to the additional following limitations: --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- 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 th e 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 be fore me on __________ by ______________________. (date) (name of person) __________________________________ (Signature of notary public) (Seal, if any) My appointment expires:__________________________
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