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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,  
 
 
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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 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:

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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 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:  
 
 
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      (3)   This durable power of attorney for h ealth 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 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:__________________________
Next: King County Washington Minor Name Change Petition Form Previous: Kansas Department of Revenue Power of Attorney Form
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