58-632.Same; form.A durable power of attorney for health care decisions shall bein substantially the following form:
DURABLE POWER OF ATTORNEY FORHEALTH CARE DECISIONSGENERAL STATEMENT OF AUTHORITY GRANTED
I,
, designate and appoint:
Name
Address:
Telephone Number:
to be my agent for health care decisions and pursuant to the languagestated 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 physicalor mental condition, and to make decisions about organ donation, autopsyand disposition of the body;
(2) make all necessary arrangements at any hospital, psychiatrichospital or psychiatric treatment facility, hospice, nursing home orsimilar institution; to employ or discharge health care personnel toinclude physicians, psychiatrists, psychologists, dentists, nurses,therapists or any other person who is licensed, certified or otherwiseauthorized or permitted by the laws of this state to administer health careas the agent shall deem necessary for my physical, mental and emotional wellbeing; and
(3) request, receive and review any information, verbal or written,regarding my personal affairs or physical or mental health includingmedical and hospital records and to execute any releases of other documentsthat may be required in order to obtain such information.
In exercising the grant of authority set forth above my agent forhealth care decisions shall:
(Here may be inserted any special instructions or statement ofthe principal's desires to be followed by the agent in exercising theauthority granted).
LIMITATIONS OF AUTHORITY
(1) The powers of the agent herein shall be limited to the extent setout in writing in this durable power of attorney for health care decisions,and shall not include the power to revoke or invalidate any previouslyexisting declaration made in accordance with the natural death act.
(2) The agent shall be prohibited from authorizing consent for thefollowing items:
.
(3) This durable power of attorney for health care decisions shall besubject to the additional following limitations:
.
EFFECTIVE TIME
This power of attorney for health care decisions shall become effective(immediately and shall not be affected by my subsequent disability orincapacity or upon the occurrence of my disability or incapacity).
REVOCATION
Any durable power of attorney for health care decisions I have previouslymade is hereby revoked.
(This durable power of attorney for health care decisions shall berevoked by an instrument in writing executed, witnessed or acknowledgedin the same manner as required herein or set out another manner ofrevocation, if desired.)
EXECUTION
Executed this ____________, at _________________________, Kansas.
________________________Principal.
This document must be:(1) Witnessed by two individuals of lawful age whoare not the agent, not related to the principal by blood, marriage oradoption, not entitled to any portion of principal's estate and notfinancially responsible for principal's health care; OR (2) acknowledged bya notary public.
58-632.Same; form.A durable power of attorney for health care decisions shall bein substantially the following form:
DURABLE POWER OF ATTORNEY FORHEALTH CARE DECISIONSGENERAL STATEMENT OF AUTHORITY GRANTED
I,
, designate and appoint:
Name
Address:
Telephone Number:
to be my agent for health care decisions and pursuant to the languagestated 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 physicalor mental condition, and to make decisions about organ donation, autopsyand disposition of the body;
(2) make all necessary arrangements at any hospital, psychiatrichospital or psychiatric treatment facility, hospice, nursing home orsimilar institution; to employ or discharge health care personnel toinclude physicians, psychiatrists, psychologists, dentists, nurses,therapists or any other person who is licensed, certified or otherwiseauthorized or permitted by the laws of this state to administer health careas the agent shall deem necessary for my physical, mental and emotional wellbeing; and
(3) request, receive and review any information, verbal or written,regarding my personal affairs or physical or mental health includingmedical and hospital records and to execute any releases of other documentsthat may be required in order to obtain such information.
In exercising the grant of authority set forth above my agent forhealth care decisions shall:
(Here may be inserted any special instructions or statement ofthe principal's desires to be followed by the agent in exercising theauthority granted).
LIMITATIONS OF AUTHORITY
(1) The powers of the agent herein shall be limited to the extent setout in writing in this durable power of attorney for health care decisions,and shall not include the power to revoke or invalidate any previouslyexisting declaration made in accordance with the natural death act.
(2) The agent shall be prohibited from authorizing consent for thefollowing items:
.
(3) This durable power of attorney for health care decisions shall besubject to the additional following limitations:
.
EFFECTIVE TIME
This power of attorney for health care decisions shall become effective(immediately and shall not be affected by my subsequent disability orincapacity or upon the occurrence of my disability or incapacity).
REVOCATION
Any durable power of attorney for health care decisions I have previouslymade is hereby revoked.
(This durable power of attorney for health care decisions shall berevoked by an instrument in writing executed, witnessed or acknowledgedin the same manner as required herein or set out another manner ofrevocation, if desired.)
EXECUTION
Executed this ____________, at _________________________, Kansas.
________________________Principal.
This document must be:(1) Witnessed by two individuals of lawful age whoare not the agent, not related to the principal by blood, marriage oradoption, not entitled to any portion of principal's estate and notfinancially responsible for principal's health care; OR (2) acknowledged bya notary public.
58-632.Same; form.A durable power of attorney for health care decisions shall bein substantially the following form:
DURABLE POWER OF ATTORNEY FORHEALTH CARE DECISIONSGENERAL STATEMENT OF AUTHORITY GRANTED
I,
, designate and appoint:
Name
Address:
Telephone Number:
to be my agent for health care decisions and pursuant to the languagestated 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 physicalor mental condition, and to make decisions about organ donation, autopsyand disposition of the body;
(2) make all necessary arrangements at any hospital, psychiatrichospital or psychiatric treatment facility, hospice, nursing home orsimilar institution; to employ or discharge health care personnel toinclude physicians, psychiatrists, psychologists, dentists, nurses,therapists or any other person who is licensed, certified or otherwiseauthorized or permitted by the laws of this state to administer health careas the agent shall deem necessary for my physical, mental and emotional wellbeing; and
(3) request, receive and review any information, verbal or written,regarding my personal affairs or physical or mental health includingmedical and hospital records and to execute any releases of other documentsthat may be required in order to obtain such information.
In exercising the grant of authority set forth above my agent forhealth care decisions shall:
(Here may be inserted any special instructions or statement ofthe principal's desires to be followed by the agent in exercising theauthority granted).
LIMITATIONS OF AUTHORITY
(1) The powers of the agent herein shall be limited to the extent setout in writing in this durable power of attorney for health care decisions,and shall not include the power to revoke or invalidate any previouslyexisting declaration made in accordance with the natural death act.
(2) The agent shall be prohibited from authorizing consent for thefollowing items:
.
(3) This durable power of attorney for health care decisions shall besubject to the additional following limitations:
.
EFFECTIVE TIME
This power of attorney for health care decisions shall become effective(immediately and shall not be affected by my subsequent disability orincapacity or upon the occurrence of my disability or incapacity).
REVOCATION
Any durable power of attorney for health care decisions I have previouslymade is hereby revoked.
(This durable power of attorney for health care decisions shall berevoked by an instrument in writing executed, witnessed or acknowledgedin the same manner as required herein or set out another manner ofrevocation, if desired.)
EXECUTION
Executed this ____________, at _________________________, Kansas.
________________________Principal.
This document must be:(1) Witnessed by two individuals of lawful age whoare not the agent, not related to the principal by blood, marriage oradoption, not entitled to any portion of principal's estate and notfinancially responsible for principal's health care; OR (2) acknowledged bya notary public.
