Kentucky Medical Power of Attorney Template
This Kentucky Medical Power of Attorney allows you to appoint someone to make healthcare decisions on your behalf in the event that you become unable to communicate your wishes. It is important to ensure that your healthcare preferences are respected and followed.
Under Kentucky law, specifically KRS 311.621, you have the right to designate an agent to make medical decisions for you. The following template can be filled out to create your own Medical Power of Attorney.
Medical Power of Attorney
I, [Your Full Name], residing at [Your Address], appoint the following individual as my agent to make healthcare decisions on my behalf:
[Agent's Full Name]
Address: [Agent's Address]
Phone Number: [Agent's Phone Number]
If my agent is unable or unwilling to act, I appoint the following individual as my alternate agent:
[Alternate Agent's Full Name]
Address: [Alternate Agent's Address]
Phone Number: [Alternate Agent's Phone Number]
This Medical Power of Attorney is effective when I am unable to make my own healthcare decisions, as determined by my attending physician. My agent is authorized to make decisions regarding:
- Medical treatment and procedures
- End-of-life care
- Access to medical records
- Placement in a healthcare facility
I understand that my agent must act in my best interest and follow my wishes, as expressed in this document or as known to my agent. If I have specific wishes regarding my healthcare, I may include them here:
[Your Specific Wishes]
This document revokes any prior Medical Power of Attorney I may have executed.
Signed this [Day] day of [Month], [Year].
_____________________________
Signature of Principal: [Your Signature]
_____________________________
Witness 1: [Witness 1 Full Name]
Address: [Witness 1 Address]
_____________________________
Witness 2: [Witness 2 Full Name]
Address: [Witness 2 Address]
This document must be signed in the presence of two witnesses who are not related to you or your agent, and who will not benefit from your estate.
It is advisable to keep a copy of this document in a safe place and provide copies to your healthcare providers and appointed agents.