DURABLE POWER OF A TT O RNEY
KNOW ALL MEN BY THESE PRESENTS:
THAT I, _____________________________________________, residing at ________________,
_______________________________________, do hereby make, constitute and appoint
_______________________________________, my true and lawful attorney, for me and in my
name, place and stead, hereby giving my said attorney full and complete authority. If the above
mentioned person chooses not to serve, I then appoint:_________________________________.
To make, execute and deliver for me and in my name, any and all deeds, document writings,
checks, drafts and notes, of all kinds and descriptions;
To generally do and perform any and all acts and things whatsoever in and about my estate,
property and affairs, in all respects and as fully as I could do if personally present;
I hereby ratify and confirm each and every act or thing which my said attorney shall do or cause
to be done by virtue thereof;
To make healthcare decisions for me. F or the pu rposes of this document, “healthcare decision”
means consent, refu sal of consent, or withdrawal of consent to any care, treatment, service or
procedure to maintain, diagnose or treat any physical or mental condition.
The person designated above is given authority to inspect and disclose any information related to
my physical and mental health, and is a uthorized to sign documents, waivers, and releases
including documents titled or purporting to be a “refusal to permit treament” and “leaving the
hospital against medical advice” and to execute any waiver or release from liability required by a
hospital or physician.
This power of attorney sh all become effective upon my disability or incapacity.
IN WITNESS WHEREOF, I have duly executed this document this ____ day of ____________,
STATE OF KENTUCKY
COUNTY OF _____________
On the ______ day of ______________, ______, before me personally came
________________________________, known to me to be the individual describ ed in, and who
executed the foregoing instrument and he/she acknowledged to me that he/she executed the
My commission expires:
NOTARY PUBLIC, STATE AT LARGE