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KRS CHAPTER 202A ? HOSPITALIZATION of the MENTALLY ILL Form
Out.
I designate _____________________________ to act as my surrogate. If this person
withdraws or is unwilling to act on my behalf, or if I revoke that person's authority to act
as my surrogate, I designate _____________________________ to act as my alternate
surrogate.
If I do not designate a surrogate, if my surrogate and alternate surrogate withdraw or are
unwilling to act on my behalf, or if I revoke their authority to act, then the health care
provider and health care facility may proceed...
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