Kansas Medical Power of Attorney Form

The Kansas medical power of attorney form is a document that provides a way for a Principal, who is near the end of their life, to delegate an Agent to make decisions with regard to the healthcare of the Principal. Making these decisions are very serious and should not be taken lightly. The Principal, prior to making any decisions, should take the time to speak with an attorney, spiritual adviser, other family members or anyone who may be able to safely guide the Principal in making this decision.

This document, however, will allow them to place limits on the powers allowed on their behalf. This document will outline all of the aspects of needed services. The Principal should carefully read through the document and seek all of the advice needed.

This document will require Notarization and attestation by two witnesses. As well, the document may be revoked by the Principal at any time they so desire.

How to Write

Step 1 – Download the document – Read the document carefully and review it prior to application of signature

Step 2 – Parties – Once the information has been read and considered, if the Principal is comfortable, the Principal may proceed

  • Enter the full name of the Principal
  • AND
  • Enter the name of the Agent
  • Address
  • Telephone Number
  • The Principal must read statements 1 through 3
  • Enter any information that the Principal would like to provide on the line provided on the form

Step 3 – Limitations of Authority – The Principal and Agent must review the three statements provided. The Agent will be unable to revoke, make any previous document invalid etc.

  • Read through number one (1). When number two(2) is reached, the Principal must be specific, in the lines provided, with regard to prohibitions of authorizing the items the Principal enters
  • The Principal may enter additional limitations in statement three (3)

Step 4 – Read the following:

  • Effective Time
  • Revocation

Step 5 – Execution of the Document:

  • Enter the date and City where the execution of the document is taking place
  • The Principal, before a Notary Public, must enter their signature

Step 6 – Witnesses – This document must be witnessed by two witnesses as described in the paragraph preceding the signature lines

  • Each witness to the document must provide their signatures and their respective addresses

Step 7 – Notarization –

  • Once the notary has witnessed all of the signatures, they shall complete all of the required information and affix their state seal in acknowledgement