Kentucky Medical Power of Attorney Form

The Kentucky medical power of attorney form is a legal document that will permit a Principal to assign an Agent to help with the health care decision making process, once the Principal is reaching  a near, end of life scenario. This document allows the Principal, while they are still of sound mind, to be vocal about their health care decisions so that when they are no longer able to make their own decisions, it will be well known what the Agent should be allowing and/or disallowing.

The Agent should approach these powers logically and with the intention of honoring the wishes of the Principal, by being aware while the Principal is able to discuss these issues with the Agent, and reviewing the documents that the Principal have prepared to ensure the Agent is granting the medical wishes of the Principal. To ensure that this occurs, the Principal should provide a copy of the document to other family members as well to their Hospice team whether in a facility or in the home.

This document will require the services of a Notary Public and Two witnesses. The Principal may revoke this document any time the wish, by delivery of notice of revocation to the Agent(s).

How to Write

Step 1 – The Parties (Princial and Agent(s)) – To begin, download the document and read the first paragraph:

  • Enter,(in the “Designate” paragraph) into the first line, the name of the Principal.
  • In the following line the Principal would enter the name of the initial Agent.
  • The final line is where the Principal would place the name of a Successor Agent (if any) who would take the place of the initial agent, in the event they become unable or unwilling to continue in this role.

Step 2 – Directive Instructions – Should the Principal choose not to  select an Agent or “surrogate,” and would choose only to provide a directive that can be followed by anyone who needs to use it to review the wishes of the Principal, check any of the boxes that would apply to the wishes of the Principal.

  • Should the Principal disagree with any of the selections, simply leave it unchecked and your family, medical team and Agent (should an Agent be selected) will work with your wishes accordingly
  • The Principal must review the final statements, prior to signing the document

Step 3 – Signatures – This document must be signed before a Notary Public

  • Enter the date of the completion of the document in dd/mm/yyyy format
  • Enter the Principal’s (Grantor) Signature
  • Provide the Principal’s Address

Witnesses – 

  • As the witnesses see the completion of the document, each witness must provide their respective signatures
  • Enter the witnesses addresses

Step 4 – Notarization –

The Notary will witness the signatories as they provide signatures to the document. The Notary shall then enter all of their required information and affix their state notary seal