Durable Power of Attorney for Health Care - kansas
STATE OF KANSAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE
DECISIONS GENERAL STATEMENT OF AUTHORITY GRANTED
I,
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, designate and appoint:
Name
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Address:
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Telephone Number:
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to be my agent for health care decisions and pursuant to the language stated 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 physical or mental condition, and to make decisions about organ
donation, autopsy and disposition of the body;
(2) make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment
facility, hospice, nursing home or similar institution; to employ or discharge health care personnel
to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person
who is licensed, certified or otherwise authorized or permitted by the laws of this state to
administer health care as the agent shall deem necessary for my physical, mental and emotional
well being; and
(3) request, receive and review any information, verbal or written, regarding my personal affairs
or physical or mental health including medical and hospital records and to execute any releases of
other documents that may be required in order to obtain such information.
In exercising the grant of authority set forth above my agent for health care decisions shall:
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