Kansas Medical Power of Attorney Form

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A Kansas medical power of attorney form allows a patient to select someone else to make health decisions when they cannot do so themselves. The agent will have specific rights and decision-making powers that must be done to the patient’s benefit. If a living will is completed, both forms should be attached to one another.

Living Will – Gives instructions to medical staff for treatment preferences and recommendations.

Laws

  • Signing Requirements – Two (2) Witnesses or a Notary Public (§ 58-632).
  • Statute – K.S.A. 58-632 (Statutory Form)

How to Write

Download: Adobe PDF, MS Word, OpenDocument

1 – This Form May Be Opened As A PDF, MS WORD, or ODT File

The form on this page will provide the required language to produce a Health Care Power of Attorney in Kansas. It may be opened by using one of the three buttons below the image preview on the right.

2 – The Principal’s Designation And Appointment Of The Attorney-in-Fact

The first line will need the First and Last Name of the Principal granting Authority here. If the Legal Name of the Grantor contains a Middle Name or Title, this should be included. 

The next blank line, under the word “Name,” should have the Legal Name of the Attorney-in-Fact entered on it. This should be immediately followed by the complete Residential Address of the Attorney-in-Fact. The final empty line in this area will request some immediate Contact Information. Enter the Daytime and/or Cell Phone Number of the Attorney-in-Fact on the line under the words “Telephone Number.”

3 – The Medical Powers Of Decisions Granted Through This Document

The next few paragraphs will give a robust description of some of the actions and decisions under the Attorney-in-Fact’s control. The Principal should read this area carefully then, give some thought to any concerns he or she may have. If there are any Special Instructions or Provisions the Principal wishes to impose upon the defined powers, they must be listed on the blank line after the statement beginning with the words “In exercising the grant of authority…”  The area labeled “Limitations of Authority, will give the Principal a place to report areas where the Principal may forbid or restrict the Attorney-in-Fact from wielding Principal Authority. If there are such areas, report them in Item 2.If the Principal only wishes to limit certain decisions the Attorney-in-Fact can make, such special instructions may be reported in Item Three.

4 – The Granting Principal’s Approval And Execution Of This Directive

The next several topics are provided to satisfy the language requirements of this document but do not need attention. The Principal should read these paragraphs then attend to the “Execution” section. Here, we will finalize this document. This process will begin with the Principal presenting the Date he or she signed this document by entering it on the blank spaces in the statement after the words “Executed this…” Once this task is completed the Principal must sign the blank space immediately below this. The area below the Principal Signature shall contain a Testimony with enough space for two Witnesses to Sign their Names and enter their Addresses. This is not a required area if the Principal Signing is Notarized. If it is not notarized, the Witness Testimony here must be signed. The last area is the Notary Public section. If two Witnesses were successfully obtained for this signing, this area may be left blank. If not, this area should be filled in with the Notary Public.
Make copies of the executed document for your agent and your physicians and providers. Also, make sure the original is in an easily accessible place for your loved ones.