Kansas Durable Power Of Attorney Form For Health Care Decisions
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3Kansas Durable Power of Attorney for Health Care Decisions
GENERAL STATEMENT OF AUTHORITY GRANTED
I, _____________________________, designate 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 disposition 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 emotional 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 to be
followed by the agent in exercising the authority granted).
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.
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