Kentucky Durable Medical Power of Attorney Form

The Kentucky Power Of Attorney For Health Care form is a legally binding form in the state of Kentucky that enables a principal to appoint an agent to be the power of attorney with regards to the patient`s health if they can no longer be responsible for the decisions due to serious illnesses. The document requires two witnesses or a notary. One witness may not be a relative or health care provider of the principal. (§ 311.625(2))

How to Write

Kentucky Medical Power Of Attorney  Form

The principal must appoint an agent and an alternative agent(s).

  • Name of principal.
  • Name of agent.
  • Names of alternative agents.


Withholding Or Withdrawing Treatment

The principal must list the type of treatment they wish to be withdrawn or withheld.

  • Initial to withdraw and withhold treatment except for the alleviation of pain.
  • Initial to receive medical treatment in any circumstance.
  • Initial to withdraw or withhold artificial hydration and nutrition.
  • Initial to receive artificial hydration and nutrition.
  • Authorize the agent to withdraw or withhold artificial hydration and nutrition.



The principal must give details regarding making a donation after death.

  • Initial to authorize the donation of all or any body parts for any purpose.
  • Initial to not authorize the donation of any body parts.



The personal details and signatures must be entered of those persons involved with this document.

  • Date.
  • Principle`s signature.
  • Principal`s address.
  • Witnesses signatures.
  • Witnesses addresses.
  • County.
  • Date.
  • Signature of notary.
  • Date commission expires.