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DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
. GENERAL STATEMENT OF AUTHORITY GRANTED. I, , designate and appoint:
(Neither the treating health care provider, as defined by subsection (c) of K.S.A. 65-4921 and amendments thereto, nor an employee of the treating health care provider, nor an employee, owner, director or officer of a facility described in K.S.A. 1989 Supp. 58-629(a)(2) may be designated as the Agent to make health care decisions under a Durable Power of Attorney for Health Care Decisions unless: (1) Related to the Principal by blood, marriage or adoption; or (2) the Principal and Agent are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conduct of religious services and actually and regularly engage in religious, benevolent, charitable or educational ministrations or the performance of health care services.)
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
to be my Agent for health care decisions and pursuant to the language stated below, on my behalf to:
a. Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose, or treat a physical or mental condition, the withdrawal and withholding of artificially provided food and fluids, and to make decisions about organ donation, autopsy and disposition of the body;
b. 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
c. 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 or other documents that may be required in order to obtain such information.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. 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.
2. The Agent shall be prohibited from authorizing consent for the following items:
3. This Durable Power of Attorney for Health Care Decisions shall be subject to the additional following limitations:
. EFFECTIVE TIME. This Power of Attorney for Health Care Decisions shall become effective
This is a durable power of attorney and the authority of my attorney in fact shall not terminate if I become disabled or in the event of later uncertainty as to whether I am dead or alive.
If a Guardian for my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
If a Guardian for my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. REVOCATION. Any Durable Power of Attorney for Health Care Decisions I have previously made is hereby revoked.
(This Durable Power of Attorney for Health Care Decisions shall be revoked by an instrument in writing executed, witnessed or acknowledged in the same manner as required herein or set out another manner of revocation, if desired.)
. SEVERABILITY. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
EXECUTION
Executed this _____ day of ____________________, _____, at _________________________, _________________________.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
This document must be: (1) Witnessed by two individuals of lawful age who are not the Agent, not related to by blood, marriage or adoption, not entitled to any portion of 's estate and not financially responsible for 's health care; OR (2) acknowledged by a Notary Public.
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It's very simple to give or receive the authority you may need using a free Kansas Medical Power of Attorney template from Rocket Lawyer:
This route, in most cases, will be notably less time-consuming than hiring your average attorney. If necessary, you may prepare a Medical PoA on behalf of a family member, and then have that person sign it when ready. Keep in mind that for this document to be accepted as legally valid, the principal must be mentally competent at the time of signing. If the principal is already unable to make their own decisions, a conservatorship generally will be required. In such a scenario, it would be best for you to speak to a lawyer .
Anyone who is over 18 ought to have a Medical Power of Attorney. Although it can be difficult to acknowledge, a time will likely come when you can no longer make healthcare decisions on your own. Typical occasions in which you might consider PoA forms to be helpful include:
Regardless of whether this Kansas Medical Power of Attorney is being drafted as part of a long-term plan or created as a result of an unexpected issue, witnesses and/or notarization are strongly encouraged as a best practice for protecting your agent if a third party questions their privileges and authority.
Sometimes, in researching the topics of elder care or estate planning, you or a loved one may see "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used interchangeably. In reality, they're one and the same. That said, it's entirely possible to establish agency over matters that are not health-related, in which case, "proxy" usually is not the term of choice.
Kansas Medical PoA forms are generally simple to make, but you or your agent(s) may need legal advice. Depending on whom you contact, some lawyers will not even accept requests to review documents that they didn't write. A better approach to consider is to request help from attorney services at Rocket Lawyer. With a Premium membership, you can request a document review from an attorney with relevant experience or pose additional questions about your Medical Power of Attorney. We are always here to answer any questions that you might have.
The cost of finding and working with a legal provider to create a Medical Power of Attorney might range between two hundred and five hundred dollars, based on your location. Rocket Lawyer can offer much more protection than many other Power of Attorney template providers that you may find. As a Rocket Lawyer Premium member, you can get up to 40% in savings when hiring an attorney from our network.
Attached to your Power of Attorney, you'll find a list of helpful tips on what to do next. As a Rocket Lawyer member, you will be able to make edits, save it as a PDF document or Word file, or sign it. Finally, your agent(s), care providers, and other impacted parties should receive a copy of your final document.
The specific rules and restrictions will be different in each state; however, in Kansas, your document will require notarization or the signatures of two witnesses. The witnesses to your document should not be anyone who is responsible for the cost of your health care, nor should they be family members (including your spouse or adopted children), heirs, or any other beneficiaries. Finally, as a basic standard, witnesses will need to be 18 years old or older, and no witness should also be your PoA agent.
See Kansas Medical/Healthcare Power of Attorney law: Chapter 58, Art. 6, Section 25
