Durable Power Of Attorney For Health Care Decisions Form printable pdf download

DURABLE POWER OF ATTORNEY FOR

HEALTH CARE DECISIONS

GENERAL STATEMENT OF AUTHORITY GRANTED

I, the undersigned, ___________________________________ , designate and appoint

Agent 1:

Name: ___________________________________

Address: _________________________________

City, State: _______________________________

Phone Number: ___________________________

Relationship: _____________________________

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, and to show particular concern for the

cost and expense thereof;

(2)

Make all necessary arrangements at any hospital, psychiatric hospital, or

psychiatric treatment facility, hospice, nursing home, or similar institution, and 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 again to show particular concern for the cost and expense

thereof;

(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.

LIMITATIONS OF AUTHORITY

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 or subsequent declaration made in accordance with the Kansas

Natural Death Act or a common law living will.

EFFECTIVE TIME

This Durable Power of Attorney for Health Care Decisions shall become effective and

exercisable immediately and shall not be affected by my subsequent disability or incapacity or upon

the occurrence of my disability or incapacity.

Durable Power of Attorney for Health Care Decisions - Page 1 of 2

Durable Power Of Attorney For Health Care Decisions Form