Kansas Medical Power of Attorney
This Medical Power of Attorney is made in accordance with the laws of the State of Kansas. It allows you to appoint someone to make healthcare decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Alternate Agent (if applicable):
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Durable Power of Attorney for Healthcare:
I, the undersigned, hereby designate the above-named agent as my attorney-in-fact for healthcare decisions. This authority shall remain in effect even if I become incapacitated.
Effective Date:
This Medical Power of Attorney becomes effective when my attending physician determines that I am unable to make my own healthcare decisions.
Healthcare Decisions Include:
- Choosing healthcare providers and facilities.
- Consenting to or refusing medical treatment.
- Accessing medical records.
- Making end-of-life decisions.
Signature:
______________________________
Principal's Signature
Date: ________________________
Witnesses:
Two witnesses must sign below. They cannot be related to you or entitled to any portion of your estate.
- Witness 1: ______________________
- Witness 2: ______________________
Date: ________________________