Kentucky Medical Power of Attorney Template
This Medical Power of Attorney is designed for use in the state of Kentucky, in accordance with Kentucky Revised Statutes § 311.621 to § 311.643. This document allows you to appoint someone to make healthcare decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ______________________________________
- Address: ____________________________________
- City, State, Zip: ____________________________
- Date of Birth: ______________________________
Agent Information:
- Name: ______________________________________
- Address: ____________________________________
- City, State, Zip: ____________________________
- Phone Number: ______________________________
Durability of Power of Attorney:
This Medical Power of Attorney shall remain in effect even if I become incapacitated.
Grant of Authority:
I hereby grant my agent the authority to make medical decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Making decisions regarding life-sustaining treatment.
Signature:
By signing below, I confirm that I am of sound mind and that I understand the contents of this document.
Principal's Signature: ___________________________
Date: _________________________________________
Witnesses:
This document must be signed in the presence of two witnesses, who are not related to the principal or the agent.
Witness 1 Signature: ____________________________
Date: _________________________________________
Witness 2 Signature: ____________________________
Date: _________________________________________
Notarization:
State of Kentucky, County of ____________________
Subscribed and sworn to before me this _____ day of __________, 20__.
Notary Public: _________________________________
My Commission Expires: ________________________