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HEALTH CARE SURROGATE DESIGNATION
By checking and initialing the appropriate lines, I specifically provide the following authorization:
If refuses or is not able to act for me, I designate:
| Surrogate Name: |
| Address: |
,
| Phone: |
| Relationship: |
as my health care surrogate.
If the person I designate as surrogate or an alternate surrogate is or ever becomes my spouse, he or she shall be ineligible to serve as my surrogate if our marriage is annulled, or we are divorced.
. 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.
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of such refusal. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed this _____ day of __________________, _____.
| Grantor Signature: | ______________________________________ |
| Name: |
| Address: |
,
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| _____ | (your Health Care Surrogate) |
| * | You should discuss the document and your wishes with any person you want to designate as a Health Care Surrogate before doing so to assure they agree to act on your behalf. |
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It's fast and easy to grant or obtain the authority you may need with a free Kentucky Medical Power of Attorney template from Rocket Lawyer:
This solution is, in many cases, notably more affordable and convenient than finding and hiring a traditional provider. If needed, you may fill out this Medical PoA on behalf of your spouse or another family member, and then have that person sign when ready. Please note that for a Power of Attorney to be accepted as legally valid, the principal must be an adult who is mentally competent at the time of signing. In the event that the principal is already unable to make their own decisions, a court-appointed conservatorship may be required. In such a situation, it's best for you to talk to a lawyer .
Every person over 18 years old should have a Medical Power of Attorney. While it may be tough to acknowledge, there might come a day when you aren't able to make your own medical decisions. Typical occasions where power of attorney may be useful include:
Whether your Kentucky Medical Power of Attorney has been drafted as part of a forward-looking plan or produced as a result of an urgent issue, witnesses and notarization are strongly encouraged as a best practice for protecting your agent if their power and authority are challenged.
Sometimes, in the process of researching the topics of estate planning or elder care, you or a loved one might hear the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used interchangeably. In actuality, they're the same. That said, please keep in mind that it's absolutely possible to get agency over affairs that are not health-related. In that case, "proxy" is not typically used.
Kentucky Medical PoA forms are usually simple, but you or your agent(s) might still have legal questions. Hiring an attorney to look over your document can take longer than you would expect if you do it on your own. An alternate approach to consider is to request help from Rocket Lawyer attorney services. Premium members have the ability to ask for guidance from an attorney with relevant experience or pose additional questions. As always, you can Live Confidently® with Rocket Lawyer by your side.
The fees associated with finding and working with a legal provider to generate a Medical Power of Attorney could add up to between $200 and $500, based on your location. Unlike most other Power of Attorney template providers that you might encounter, Rocket Lawyer gives Premium membership holders up to a 40% discount when hiring a lawyer, so an attorney can assess the situation and take action if you ever need assistance.
With a Premium membership, you will be able to edit it, save it in PDF format or as a Word file, and/or print it. To make your Power of Attorney legally binding, you must sign it. You should provide a copy of your fully signed document to your agent(s), care providers, and other impacted parties.
The specific requirements governing PoA forms are different in each state; however, in Kentucky, your document will need notarization or the signatures of two witnesses. Witnesses to a Healthcare PoA must not be your attending physician or anyone responsible for your healthcare costs, nor can they be affiliated with your healthcare facility unless providing notary services. Relatives or other beneficiaries are also restricted. As a basic principle, your witness(es) should be at least 18 years old, and no witness should simultaneously be acting as your agent.
See Kentucky Medical/Healthcare Power of Attorney law: § 311.629
