"Durable Power of Attorney for Healthcare Decisions" - Kansas

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DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
DECISION TO NAME SOMEONE TO SPEAK FOR ME
I,
,
appoint the following person(s) to make healthcare decisions for me when I
(your name) ___________________________________________
am unable to make or communicate my own wishes:
Agent may not be the treating healthcare provider, an employee of the treating healthcare provider, or an employee, owner,
director or officer of a facility, unless that person is a relative or is bound to you by common vows to a religious life.
PLEASE PRINT:
Name of Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
Name of First Alternate Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
Name of Second Alternate Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
This power of attorney for healthcare decisions shall become effective when I am unable to make decisions or unable to communicate
my wishes regarding healthcare. This power of attorney for healthcare decisions shall not be affected by my subsequent disability or
incapacity. Any durable power of attorney for healthcare decisions I have previously made is hereby revoked.
AUTHORITY GRANTED
My agent shall authorize consent for the following special
My healthcare agent may:
instructions:
I I
1. Consent, refuse consent, or withdraw consent to any care,
I wish to be a donor for organs and tissues.
I I
treatment, service or procedure to maintain, diagnose or
I have attached information about treatment choices I
treat a physical or mental condition;
wish to have honored by my agent.
2. Make all arrangements for me at any hospital, treatment
LIMITATIONS ON AUTHORITY GRANTED
facility, hospice, nursing home or similar institution;
My healthcare agent may not:
3. Employ or discharge healthcare personnel including
physicians, psychiatrists, dentists, nurses, therapists or
1. Exceed the powers set out in writing in this document; or
other persons who provide treatment for me;
2. Revoke any existing Living Will Declaration I may have.
I I
4. Request, receive and review any information, spoken or
I have attached information about special limitations
written, regarding my personal affairs or physical or
I wish to have honored by my agent.
mental health including medical and hospital records,
and execute any releases or other documents that may be
required in order to obtain such information; and
X __________________________________________
5. Make decisions about organ and tissue donations,
signature
date
autopsy and the disposition of my body.
Notary Public:
Notary Seal:
STATE OF
COUNTY OF
This instrument was acknowledged before me this
day of
(month, year)
Signature of Notary
My appointment expires:
or
Witnesses: (witnesses may not be the agent or a relative, or beneficiary of the principal)
X ___________________________________________________
Date: _________________________________________________
(Signature)
X ___________________________________________________
Date: _________________________________________________
(Signature)
This document is based on Kansas Statutes Annotated, (58-625 through 632)
Copy protected. Additional forms and information are available through
Kansas Health Ethics, Inc., 5900 East Central Ave., Suite 101, Wichita, KS 67208.
Telephone (316) 684-1991
www.kansashealthethics.org
Form #115 Rev. 07/2003.
Reprinted 4/2005
DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
DECISION TO NAME SOMEONE TO SPEAK FOR ME
I,
,
appoint the following person(s) to make healthcare decisions for me when I
(your name) ___________________________________________
am unable to make or communicate my own wishes:
Agent may not be the treating healthcare provider, an employee of the treating healthcare provider, or an employee, owner,
director or officer of a facility, unless that person is a relative or is bound to you by common vows to a religious life.
PLEASE PRINT:
Name of Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
Name of First Alternate Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
Name of Second Alternate Agent:
Telephone
(Day)
(Evening)
Agent’s address:
City
State/Zip
This power of attorney for healthcare decisions shall become effective when I am unable to make decisions or unable to communicate
my wishes regarding healthcare. This power of attorney for healthcare decisions shall not be affected by my subsequent disability or
incapacity. Any durable power of attorney for healthcare decisions I have previously made is hereby revoked.
AUTHORITY GRANTED
My agent shall authorize consent for the following special
My healthcare agent may:
instructions:
I I
1. Consent, refuse consent, or withdraw consent to any care,
I wish to be a donor for organs and tissues.
I I
treatment, service or procedure to maintain, diagnose or
I have attached information about treatment choices I
treat a physical or mental condition;
wish to have honored by my agent.
2. Make all arrangements for me at any hospital, treatment
LIMITATIONS ON AUTHORITY GRANTED
facility, hospice, nursing home or similar institution;
My healthcare agent may not:
3. Employ or discharge healthcare personnel including
physicians, psychiatrists, dentists, nurses, therapists or
1. Exceed the powers set out in writing in this document; or
other persons who provide treatment for me;
2. Revoke any existing Living Will Declaration I may have.
I I
4. Request, receive and review any information, spoken or
I have attached information about special limitations
written, regarding my personal affairs or physical or
I wish to have honored by my agent.
mental health including medical and hospital records,
and execute any releases or other documents that may be
required in order to obtain such information; and
X __________________________________________
5. Make decisions about organ and tissue donations,
signature
date
autopsy and the disposition of my body.
Notary Public:
Notary Seal:
STATE OF
COUNTY OF
This instrument was acknowledged before me this
day of
(month, year)
Signature of Notary
My appointment expires:
or
Witnesses: (witnesses may not be the agent or a relative, or beneficiary of the principal)
X ___________________________________________________
Date: _________________________________________________
(Signature)
X ___________________________________________________
Date: _________________________________________________
(Signature)
This document is based on Kansas Statutes Annotated, (58-625 through 632)
Copy protected. Additional forms and information are available through
Kansas Health Ethics, Inc., 5900 East Central Ave., Suite 101, Wichita, KS 67208.
Telephone (316) 684-1991
www.kansashealthethics.org
Form #115 Rev. 07/2003.
Reprinted 4/2005