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Kansas statutory health care form
Download the August 2026 Kansas Durable Power of Attorney for Health Care Decisions packet, the statutory form under K.S.A. 58-632, for appointing an agent to make health care decisions if you cannot speak for yourself. Get the form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific durable power of attorney for health care decisions packet, reviewed against the current Kansas statute and ready for instant secure access.
Tracks the K.S.A. 58-632 form, including the statutory grant of authority, special-instruction and limitation lines, and both statutory execution paths, not a generic national template.
Initial one election so the agency starts immediately or only upon disability or incapacity, matching the statutory alternatives under K.S.A. 58-632 and 58-629(b).
Complete the form on your device, then print and sign with two qualifying witnesses or a notary. Your personal details are never entered into an online form builder.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete statutory text below before purchasing. Your licensed download (editable Word and fillable PDF) is delivered after checkout.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
Kansas · K.S.A. 58-632
GENERAL STATEMENT OF AUTHORITY GRANTED
I, ________________________________________, designate and appoint:
Name: __________________________________________________
Address: ________________________________________________
__________________________________________________________
Telephone Number: ____________________________________
to be my agent for health care decisions and pursuant to the language stated below, on my behalf to:
(1) Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition, and to make decisions about organ donation, autopsy and disposition of the body;
(2) make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care as the agent shall deem necessary for my physical, mental and emotional well being; and
(3) request, receive and review any information, verbal or written, regarding my personal affairs or physical or mental health including medical and hospital records and to execute any releases of other documents that may be required in order to obtain such information.
In exercising the grant of authority set forth above my agent for health care decisions shall:
______________________________________________________________
______________________________________________________________
(Here may be inserted any special instructions or statement of the principal's desires to be followed by the agent in exercising the authority granted).
LIMITATIONS OF AUTHORITY
(1) The powers of the agent herein shall be limited to the extent set out in writing in this durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural death act.
(2) The agent shall be prohibited from authorizing consent for the following items:
______________________________________________________________
______________________________________________________________
(3) This durable power of attorney for health care decisions shall be subject to the additional following limitations:
______________________________________________________________
______________________________________________________________
EFFECTIVE TIME
This power of attorney for health care decisions shall become effective (select and initial ONE):
(___) immediately and shall not be affected by my subsequent disability or incapacity; OR
(___) upon the occurrence of my disability or incapacity.
Unless you specifically choose the immediate option above, agent powers are not effective until your attending physician determines impairment (K.S.A. 58-629(b)).
REVOCATION
Any durable power of attorney for health care decisions I have previously made is hereby revoked.
(This durable power of attorney for health care decisions shall be revoked by an instrument in writing executed, witnessed or acknowledged in the same manner as required herein or set out another manner of revocation, if desired.)
EXECUTION
Executed this ________________, at ____________________________, Kansas.
__________________________________________
Principal
This document must be: (1) Witnessed by two individuals of lawful age who are not the agent, not related to the principal by blood, marriage or adoption, not entitled to any portion of principal's estate and not financially responsible for principal's health care; OR (2) acknowledged by a notary public.
First Witness
__________________________________________
Signature of Witness
Printed name: ________________________________________
Address: ________________________________________________
Second Witness
__________________________________________
Signature of Witness
Printed name: ________________________________________
Address: ________________________________________________
(OR)
NOTARY ACKNOWLEDGMENT
Use this path instead of the two-witness path. Either two qualifying adult witnesses or a notary acknowledgment satisfies K.S.A. 58-629(e).
STATE OF ______________________)
) SS.
COUNTY OF ____________________)
This instrument was acknowledged before me on ________________ (date) by ____________________________ (name of person).
__________________________________________
Signature of Notary Public
Printed name of notary: ____________________________________
(Seal, if any)
My appointment expires: ____________________________
Copies
Legal currency, verified
This Kansas form lets an adult appoint an agent to make health care decisions, including consent to or refusal of treatment, under K.S.A. 58-625 through 58-632.
Tracks the statutory form in K.S.A. 58-632. The form text has been unchanged since L. 1989, ch. 181, § 8. Verified August 2026 against the Kansas Revisor of Statutes text. It is not a government publication.
Sign and date before two qualifying adult witnesses, or acknowledge before a notary public. Either path satisfies K.S.A. 58-629(e). Witnesses must not be the agent, related by blood, marriage, or adoption, entitled to any portion of your estate, or financially responsible for your health care.
The statutory grant of authority, special-instruction and limitation lines, mutually exclusive effective-time elections, stacked principal and witness execution blocks, the notary acknowledgment alternative, and the statutory Copies heading. A completed sample PDF is available separately as a filled-in reference.
Editable Word and true fillable PDF of the complete Kansas durable power of attorney for health care decisions. Customer support and lifetime update access are included with your purchase. The separate Kansas Living Will Declaration is not included.
This form is not legal advice. Consider speaking with a Kansas licensed attorney about your situation.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
Yes. K.S.A. 58-632 provides that a durable power of attorney for health care decisions shall be in substantially the following form. This packet tracks that statutory text. The form language has been unchanged since L. 1989, ch. 181, § 8. Verified in August 2026 against the Kansas Revisor of Statutes. It is not a government publication.
You sign and date the instrument. Then either two qualifying adult witnesses sign, or you acknowledge the instrument before a notary public. Either path satisfies K.S.A. 58-629(e).
A witness must be of lawful age and must not be the agent, related to you by blood, marriage, or adoption, entitled to any portion of your estate, or financially responsible for your health care.
You initial one effective-time election. Powers may begin immediately and continue despite later disability, or only upon disability or incapacity. Unless you choose the immediate option, powers are not effective until your attending physician determines impairment (K.S.A. 58-629(b)).
No. This instrument names a health care decision maker. A Kansas Living Will Declaration under K.S.A. 65-28,103 states treatment directions for a certified terminal condition. The statutory form also says the agent may not revoke a previously existing Natural Death Act declaration.
Both contain the same Kansas durable power of attorney for health care decisions text. Use the editable Word file to type details, or the fillable PDF to complete fields on screen. Print the finished document and sign on paper with two witnesses or a notary.