Durable Power Of Attorney
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1DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
(Pursuant to Kansas Statutes Annotated, Section 58625 through 632)
DECISION TO NAME SOMEONE TO SPEAK FOR ME
I, ______________________________, appoint the following person(s) to make healthcare decisions for
me when I am unable to make or communicate my own wishes.
(Agent may not be the treating health care provider,
an employee of the treating health care 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.)
Name of Agent: ____________________________________ Telephone: _________________________
Day
Evening
Address: ________________________________ City: _________________ State/Zip______________
Name of 1st Alternate Agent: ________________________ Telephone: _________________________
Day
Evening
Address: ________________________________ City: _________________ State/Zip______________
Name of 2nd Alternate Agent: ________________________ Telephone: _________________________
Day
Evening
Address: ________________________________ City: _________________ State/Zip______________
This Power of Attorney for Health Care Decisions shall become effective when I am unable to make
decisions or unable to communicate my wishes regarding health care. This Power of Attorney for
Health Care Decisions shall not be affected by my subsequent disability or incapacity. Any Durable
Power of Attorney for Health Care Decisions I have previously made is hereby revoked.
AUTHORITY GRANTED
My healthcare agent may:
1. Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to
maintain, diagnose or treat a physical or mental condition;
2. Make all arrangements for me at any hospital, treatment facility, hospice, nursing home or similar
institution;
3. Employ or discharge health care personnel including physicians, psychiatrists, dentists, nurses,
therapists or other persons who provide treatment for me;
4. Request, receive and review any information, spoken or written, regarding my personal affairs or
physical or 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
5. Make decisions about organ and tissue donations, autopsy and the disposition of my body.
My agent shall authorize consent for the following special instructions:
¨ I wish to be a donor of organs and tissues.
¨ I have attached information about treatment choices I wish to have honored by my agent.
LIMITATIONS ON AUTHORITY GRANTED
My healthcare agent may not:
1. Exceed the powers set out in writing in this document; or
2. Revoke any existing Living Will Declaration I may have.
¨ I have attached information about special limitations I wish to have honored by my agent.
x_________________________________________
__________________________________
(Signature)
(Date)
Notary Public:
STATE OF _____________________ COUNTY OF ___________________
NOTARY SEAL:
This instrument was acknowledged before me this ______ day of _________, 20__.
Signature of Notary: ___________________________________________________
OR
WITNESSES (May not be an agent or next of kin):
X___________________________________________
__________________________________________
(Signature)
(Date)
X___________________________________________
__________________________________________
(Signature)
(Date)
Form #115 07/03. Ó Kansas Health Ethics, Inc., Telephone (316) 6841991.
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