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Kansas My appointment expires:__________________________ -3- acknowledged before me on ____________________________ (date) by _________________________________ (name of person) ______________________________________ (Signature of notary public) (Seal, if any) itness Signature) Print Name: ___________________________________ Address: ______________________________________ (OR) STATE OF KANSAS ) )SS. COUNTY OF ________________________ ) This instrument was__________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (W by blood, marriage or adoption, not entitled to any portion of principal's estate and not financially responsible for principal's health care; OR (2) acknowledged before a notary public. ___________f Principal: ___________________________________________________________ -2- This document must be: (1) Witnessed by two individuals of lawful age who are not the agent, not related to the principalessed or acknowledged in the same manner as required herein or set out another manner of revocation, if desired. EXECUTION Executed this ____________, at _________________________, Kansas. Signature ower of attorney for health care decisions I have previously made is hereby revoked. This durable power of attorney for health care decisions shall be revoked by an instrument in writing executed, witncare decisions shall become effective (immediately and shall not be affected by my subsequent disability or incapacity or upon the occurrence of my disability or incapacity). REVOCATION Any durable po_______________________________________________________________________ ______________________________________________________________________________ EFFECTIVE TIME This power of attorney for health his durable power of attorney for health care decisions shall be subject to the additional following limitations: ______________________________________________________________________________ ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (3) Texisting declaration made in accordance with the natural death act. -1- (2) The agent shall be prohibited from authorizing consent for the following items: __________________________________________ the agent herein shall be limited to the extent set out in writing in this durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate any previously ______________________________________________________________________________ ______________________________________________________________________________ LIMITATIONS OF AUTHORITY (1) The powers ofnt in exercising the authority granted).: ______________________________________________________________________________ ______________________________________________________________________________ rcising the grant of authority set forth above my agent for health care decisions shall (Here may be inserted any special instructions or statement of the principal's desires to be followed by the age 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 exeis 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, regardingh 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 thion 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 healtonsent, 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 disposit_______________ (Address) ________________________________ (Telephone Number) to be my agent for health care decisions and pursuant to the language stated below, on my behalf to: (1) Consent, refuse c______________________________________ , designate and appoint: _____________________________________________________________ (Name) maintaining an address at: ________________________________________s is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Durable Power of Attorney for Health Care Decisions GENERAL STATEMENT OF AUTHORITY GRANTED I, _______________________ney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these form without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attors are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be usedrms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These form to the terms of a durable power of attorney for health care decisions without knowledge of its invalidity shall be immune from liability that may be incurred or imposed from such action. [_] These folic. (f) Death of the principal shall not prohibit or invalidate acts of the agent in arranging for organ donation, autopsy or disposition of body. -2- (g) Any person who in good faith acts pursuantf intestate succession of this state or under any will of the principal or codicil thereto, or directly financially responsible for the principal's health care; or (2) acknowledged before a notary pubses at least 18 years of age neither of whom shall be the agent, related to the principal by blood, marriage or adoption, entitled to any portion of the estate of the principal according to the laws oaritable or educational ministrations or the performance of health care services. (e) A durable power of attorney for health care decisions shall be: (1) Dated and signed in the presence of two witnesof the same community of persons who are bound by vows to a religious life and who conduct or assist in the conduct of religious services and actually and regularly engage in religious, benevolent, ch make health care decisions under a durable power of attorney for health care decisions unless: (1) Related to the principal by blood, marriage or adoption; or (2) the principal and agent are members eto, nor an employee of the treating health care provider, nor an employee, owner, director or officer of a facility described [in] subsection (a)(2) in K.S.A. 58-629 may be designated as the agent tos, the agent has a duty to act consistent with the expressed desires of the principal. (d) Neither the treating health care provider, as defined by subsection (c) of K.S.A. 65-4921 and amendments there with the tenets and practices of any church or religious denomination of which the principal is a member. (c) In exercising the authority under the durable power of attorney for health care decision this act shall be construed as prohibiting an agent from providing treatment by spiritual means through prayer alone and care consistent therewith, in lieu of medical care and treatment, in accordancattending physician, as defined in subsection (a) of K.S.A. 65-28,102 and amendments thereto, unless the durable power of attorney for health care decisions specifically provides otherwise. Nothing inipal in accordance with the natural death act. No agent powers conveyed pursuant to this section shall be effective until the occurrence of the principal's impairment as determined by the principal's ited to the extent set out in writing in the durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate a previously existing declaration by the princl health including medical and hospital records and to execute any releases of other documents that may be required in order to obtain such information. (b) The powers of the agent herein shall be limhysical, mental and emotional well being of the principal; and -1- (3) request, receive and review any information, verbal or written, regarding the principal's personal affairs or physical or menta 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 the pic hospital or psychiatric treatment facility, hospice, nursing home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychologists, dentists,treat a physical or mental condition, and to make decisions about organ donation, autopsy, and disposition of the body; (2) make all necessary arrangements for the principal at any hospital, psychiatr of attorney for health care decisions may convey to the agent the authority to: (1) Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose or TTERSOF ATTORNEY 58-629. Same; authority of agent; limitations on agent's power; persons not to be designated as agents; witnesses and acknowledgment; effect of death of principal. (a) A durable powerf the principal that the authority conferred shall be exercisable notwithstanding the principal's subsequent disability or incapacity. Chapter 58.--PERSONAL AND REAL PROPERTY Article 6.--POWERS AND LEy or incapacity of the principal" or "this power of attorney for health care decisions shall become effective upon the disability or incapacity of the principal," or similar words showing the intent och a principal designates another as the principal's agent in writing and the writing contains the words "this power of attorney for health care decisions shall not be affected by subsequent disabilitERTY Article 6.--POWERS AND LETTERSOF ATTORNEY 58-625. Durable power of attorney for health care decisions; meaning. A durable power of attorney for health care decisions is a power of attorney by whites Chapter 58 Article 6 et. Seq. (58-632) The following are useful excerpts from the Kansas Statutes relating to the Kansas Power of Attorney for Health Care Form. Chapter 58.--PERSONAL AND REAL PROPorney for Health Care) ; (2) Kansas Durable Power of Attorney for Health Care Decisions (Power of Attorney for Health Care) Form. This Kansas Power of Attorney for Health Care is based on Kansas StatuInformation and Instructions Kansas Power of Attorney for Health Care This package contains (1) Information and Instruction for Kansas Durable Power of Attorney for Health Care Decisions (Power of Att Kansas