Fill and Sign the Kansas Statutory Durable Power of Attorney for Health Care Form

Page 1 of 4 DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS (K.S.A 58 -632) GENERAL STATEMENT OF AUTHORITY GRANTED I, _____________________________________ , designa te and appoint: Name: _____________________________________ Address: ______ ___________________________________________________ Telephone Number: _____________________________________ 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 dispositi on 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 emotion al 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: _________________________________________________________________ (Here may be inserted any special instructions or statement of the principal's desires tobe followed by the agent in exercising the authority granted). Page 2 of 4 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 au thorizing consent for the following items: __________________________________________________________ _______ _________________________________________________________________ _________________________________________________________________ (3) This durable power of attorney for health care decisions shall be subject to the additional following limitations: _________________________________________________________________ __________________________ _______________________________________ _________________________________________________________________ EFFECTI VE 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. Page 3 of 4 (This durable power of attorney for health care decisions shall be revoked by an instrument in writing executed, witne ssed 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 heal th care; OR (2) acknowledged by a notary public. ______________________________________________________________________________ Witness _________________________________________________________ Address _________________________ _____________________________________________________ Witness __________________________ _______________________________ Address (OR) STATE OF _____________________________________ COUNTY OF _____________________________________ Page 4 of 4 This instrument was acknowledged before me on _____________________________________ (date) by _____________________________________ (name of person). ____________________________________ Signature of notary public (Seal, if any) My appointment expires: __________________________