Kentucky Medical Power of Attorney
This document serves as a Medical Power of Attorney in accordance with Kentucky state laws. It allows you to designate an individual to make healthcare decisions on your behalf in the event that you become unable to do so. Please fill in the blanks with your personal information where indicated.
Principal Information:
- Full Name: _____________________________
- Address: ______________________________
- City, State, Zip Code: ________________
- Date of Birth: ________________________
Agent Information:
- Full Name: _____________________________
- Address: ______________________________
- City, State, Zip Code: ________________
- Phone Number: ________________________
Statement of Authority:
I, _____________________________, hereby appoint _____________________________ as my agent to make healthcare decisions on my behalf if I am unable to make those decisions myself. This authority includes, but is not limited to:
- Making decisions about medical treatment and procedures.
- Accessing my medical records and information.
- Consenting to or refusing medical care.
Effective Date:
This Medical Power of Attorney becomes effective upon my inability to make my own healthcare decisions, as determined by my attending physician.
Revocation of Prior Powers of Attorney:
Any prior Medical Power of Attorney executed by me is hereby revoked.
Signatures:
By signing below, I confirm that I understand the contents of this document and the authority I am granting to my agent.
Principal's Signature: ___________________________
Date: ___________________________
Witness Signature: ___________________________
Date: ___________________________
Notary Public:
State of Kentucky
County of ___________________________
Subscribed, sworn to, and acknowledged before me by _____________________________ this ____ day of ____________, 20__.
Notary Public Signature: ___________________________
My Commission Expires: ___________________________