Kansas Medical Power of Attorney
This Kansas Medical Power of Attorney is created in accordance with the laws of the State of Kansas. It allows you to designate an individual to make medical decisions on your behalf in the event that you become unable to make those decisions yourself.
Principal Information:
- Name: ___________________________________________
- Address: _________________________________________
- City, State, Zip: ________________________________
- Date of Birth: ___________________________________
Agent Information:
- Name: ___________________________________________
- Address: _________________________________________
- City, State, Zip: ________________________________
- Phone Number: ___________________________________
Effective Date: This Medical Power of Attorney shall become effective upon the determination by my attending physician that I am unable to make my own medical decisions.
Agent's Authority: My agent shall have the authority to make decisions regarding my medical treatment, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records.
- Make decisions regarding life-sustaining treatment.
- Arrange for my admission to or discharge from medical facilities.
Signature:
By signing below, I confirm that I am of sound mind and that I understand the contents of this document.
_____________________________
Signature of Principal
_____________________________
Date
Witnesses:
This document must be witnessed by two individuals who are not related to the principal or the agent.
- Name: ___________________________________________
- Signature: ________________________________________
- Date: ____________________________________________
- Name: ___________________________________________
- Signature: ________________________________________
- Date: ____________________________________________
Notary Public:
State of Kansas, County of _______________
Subscribed and sworn to before me this ____ day of __________, 20__.
_____________________________
Notary Public Signature
My commission expires: ____________________________