This Kansas Medical Power of Attorney is created in accordance with the Kansas Statutes, specifically addressing the delegation of certain medical decisions to an appointed agent. This document serves to ensure that the person's medical treatment preferences are respected at times when they are unable to communicate their desires due to illness or incapacity.
Please provide the needed information in the blanks provided below to ensure this document accurately reflects your wishes and complies with Kansas law.
Principal's Information:
- Full Name: ___________________________________________
- Address: _____________________________________________
- City, State, ZIP: _____________________________________
- Date of Birth: ________________________________________
- Social Security Number (optional): ______________________
Agent's Information:
- Full Name of Agent: ____________________________________
- Address of Agent: ______________________________________
- City, State, ZIP of Agent: ______________________________
- Primary Phone Number: __________________________________
- Alternate Phone Number: _______________________________
Alternate Agent's Information (if any):
- Full Name of Alternate Agent: ___________________________
- Address of Alternate Agent: ____________________________
- City, State, ZIP of Alternate Agent: _____________________
- Primary Phone Number: __________________________________
- Alternate Phone Number: _______________________________
I, the Principal named above, appoint the Agent named above to make health care decisions on my behalf, as authorized in this document, according to the laws of the State of Kansas. This power includes, but is not limited to, the power to consent, refuse consent, or withdraw consent to any and all types of medical care, treatment, surgical procedures, or diagnostic procedures.
I declare that this power of attorney has immediate effect and remains effective even if I become disabled, incapacitated, or incompetent, in accordance with Kansas law. The authority of my Agent shall be subject to the following conditions or limitations:
_________________________________________________________
_________________________________________________________
My Agent is not authorized to make any decisions regarding the withholding or withdrawal of life-sustaining treatment unless stated otherwise in this document or unless my attending physician certifies in writing that such treatment would only serve to prolong the process of my dying or that I am in an irreversible coma or persistent vegetative state with no reasonable chance of recovery.
This Medical Power of Attorney will remain in effect until I revoke it in writing and notify my Agent and my health care provider of the revocation.
Signed this ________ day of ________________, 20____.
Principal's Signature: ______________________________________
State of Kansas
County of ____________________
On this day, personally appeared before me, the undersigned notary public, __________________________________(Name of Principal), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged that he/she/they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary's Signature: ________________________________________
My commission expires: ____________________________________