[THIS SECTION IS FOR YOUR INFORMATION ONLY. IT WILL NOT BE PRINTED.]
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record. It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate. The Health Care Power of Attorney should be reviewed: if the Agent or the Alternate Agent is no longer able to serve; if the Agent is your spouse and you become separated or divorced; or if you wish to revise your desires as stated in the document.
HCP_KS12
{NEXT_?}
AGENT: Neither the treating health care provider, as defined by subsection (c) of K.S.A. 65-4921 and amendments thereto, nor an employee of the treating health care provider, nor an employee, owner, director or officer of a facility described in K.S.A. 1989 Supp. 58-629(a)(2) may be designated as the Agent to 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 of 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, charitable or educational ministrations or the performance of health care services.
HCP_KS01
HKS01005
Name: |
HCP_KS01
SWho is this Durable Power of Attorney for Health Care Decisions being prepared for?
Enter the name of the person who will act as Agent or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear in the previous question. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
HKS01015
Relation:#|
HCP_KS01
;What is the Agent's relationship, if any, to the Principal?
{NEXT_?}
The following items:#|
HCP_KS06
4What will the Agent NOT be authorized to consent to?
HKS06008
The following limitations:#|
HCP_KS06
8What other limitations will this document be subject to?
{NEXT_?}
Yes, include limitations section.
HCP_KS06
?Do you wish to impose any limitations on the Agent's authority?
Enter the name of the person who will serve as Guardian if one is required by legal proceedings. Use the P.I. Manager to select and paste a record. This person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
{NEXT_?}
Yes, include Guardian section.
HCP_KS08
#Do you wish to nominate a Guardian?
HKS08002
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Yes, include additional revocation statement.
HCP_KS09
This document may be revoked by a written revocation signed by the Principal and witnesses. Do you wish to specify another means of revoking this document?
HKS09003
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At any time, and in any mannerOther revocation method
HCP_KS09
6Under what circumstances may this document be revoked?
WITNESS STATEMENT: I am not the person appointed as Agent or Alternate Agent, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.
I further declare that I am not related to the Principal by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of the Principal or entitled to any part of the estate of the Principal under a Will now existing or by operation of law.
HCP_KS11
HKS11002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_KS11
2What are the names and addresses of the witnesses?
{NEXT_?}
HKS11002
WitnessesNotary
HCP_KS11
/Who will acknowledge the Principal's signature?
Enter an X if a Notary Public will be signing the document. Press [Ctrl+F1] for more information.
HKS11000
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_KS02
MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
IGN04006
IGN04011
IGN04022
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_KS02
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
Enter an X to withhold life-sustaining procedures if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining procedures if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
IGN04022
Specific desires:#|
HCP_KS02
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
HCP_KS02
LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
{NEXT_?}
YesNo
HCP_KS02
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
{NEXT_?}
Yes, include life-sustaining procedures section.
HCP_KS02
GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
HCP_KS03
IWhat special provisions, if any, do you wish to include in this document?
If desired, enter any special health care provisions that you would like to include in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
{NEXT_?}
IGN06255
Values and preferences:#|
HCP_KS04
DWhat personal values, if any, do you wish to state in this document?
If desired, specify any values and preferences about health care. For example, describe values or religious preferences, or your desires regarding the location of treatment. Press [Ctrl+F1] for more information.
=Who, if anyone, will be designated as Second Alternate Agent?
If desired, enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record. You do not have to name a second Alternate Agent.
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