Kansas Medical Power of Attorney
This document serves as a Kansas Medical Power of Attorney, allowing you to appoint someone to make medical decisions on your behalf in accordance with Kansas state laws.
Principal's Information:
Name: ____________________________________
Address: __________________________________
City: ____________________ State: ________ Zip Code: __________
Date of Birth: ___________________________
Agent's Information:
Name: ____________________________________
Address: __________________________________
City: ____________________ State: ________ Zip Code: __________
Phone Number: ___________________________
Effective Date:
This Medical Power of Attorney shall become effective on: ____________________.
Durability:
This document will remain in effect until revoked by the Principal or until the Principal's death.
Agent's Authority:
The Agent shall have the authority to make decisions regarding the Principal's medical care, including but not limited to:
- Consent to or refuse medical treatment.
- Access medical records.
- Make decisions regarding life-sustaining treatment.
- Hire or fire medical personnel.
Signature of Principal:
_____________________________ Date: ________________
Witnesses:
- Name: ___________________________ Signature: _______________________ Date: ________________
- Name: ___________________________ Signature: _______________________ Date: ________________
Notary Public:
State of Kansas
County of ______________________
Subscribed and sworn before me this _____ day of ____________, 20__.
_____________________________ (Notary Public Signature)
My commission expires: ________________