Kentucky Medical Power of Attorney
This Kentucky Medical Power of Attorney is created in accordance with the Kentucky Living Will Directive Act. It grants authority to a chosen representative to make medical decisions on behalf of the principal when the principal is unable to make such decisions themselves.
Principal Information:
- Full Name: ____________________________________________
- Date of Birth: _________________________________________
- Address: ______________________________________________
- City: ______________________ State: KY Zip: ____________
- Phone Number: _________________________________________
Designation of Healthcare Surrogate:
I, _________________ [Principal's Name], hereby designate the following individual as my Healthcare Surrogate to make medical decisions for me if I am unable to communicate my medical treatment preferences myself.
- Surrogate’s Full Name: __________________________________
- Relationship to Principal: _______________________________
- Phone Number: __________________________________________
- Alternate Phone Number: ________________________________
Alternate Healthcare Surrogate:
In the event my primary Healthcare Surrogate is unavailable, unwilling, or unable to act on my behalf, I designate the following individual as my alternate Healthcare Surrogate.
- Alternate Surrogate’s Full Name: ___________________________
- Relationship to Principal: _________________________________
- Phone Number: ___________________________________________
- Alternate Phone International: _____________________________
Special Directions:
Any specific limitations on the Healthcare Surrogate’s authority to make medical decisions on my behalf are as follows:
_________________________________________________________
_________________________________________________________
Effective Date and Signatures:
This document becomes effective when I, the principal, am unable to make informed decisions regarding my medical treatment. It is signed in the presence of two witnesses, who are not my healthcare provider, an employee of my healthcare provider, the operator of a community care facility, or an employee of an operator of a community care facility. The witnesses cannot be related to me by blood, marriage, or adoption, nor entitled to any part of my estate upon my death under a will or codicil thereto or by operation of law at the time of execution of this Advance Directive.
Principal's Signature: ________________________________ Date: _______________
Witness #1 Signature: ________________________________ Date: _______________
Print Name: ______________________________________________________________
Witness #2 Signature: ________________________________ Date: _______________
Print Name: ______________________________________________________________
