Durable Power Of Attorney For Health Care Decisions Form (Page 2 of 2) in pdf

LIMITATIONS OF AUTHORITY

The powers of my agent 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 Natural Death Act or any common law living will declaration.

The agent shall be prohibited from authorizing consent for the following items:

__________________________________________________________________________________________________

This durable power of attorney for health care decisions shall be subject to the additional following limitations:

__________________________________________________________________________________________________

WHEN EFFECTIVE

This durable power of attorney for health care decisions shall become effective (initial one):

_____ Immediately and shall not be affected by my subsequent disability, incapacity, or death; or

_____ Upon the occurrence of my disability or incapacity.

REVOCATION

Any durable power of attorney for health care decisions which I have previously made is hereby revoked. This

durable power of attorney for health care decisions may be revoked by any instrument in writing executed, witnessed, or

acknowledged in the same manner as this document.

EXECUTION

Executed this ______ day of ___________________, 20____, at ______________, Kansas.

_________________________________________

Principal

This document must be dated and signed in the presence of two witnesses OR acknowledged by a notary public.

(1)

Witnesses – 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 the principal’s estate; and not financially responsible for principal’s health care.

Witness ______________________________________

Address ______________________________________

(2)

STATE OF KANSAS

)

) ss:

COUNTY OF ____________________ )

This instrument was acknowledged before me on this _____ day of ___________________, 20___.

Signature of Notary Public

_____________________________________

My appointment expires:

_____________________________________

00003720S

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DPOA

Discuss this document and your treatment preferences with your physician(s), family members, and designated agent,

and provide them with a signed copy or photocopy.

Durable Power Of Attorney For Health Care Decisions Form Page 2