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KENTUCKY DURABLE POWER OF ATTORNEY FOR HEALTH CARE
[PRINT YOUR NAME AND ADDRESS]
1. Designation of Health Care Agent.
I, ____________________ (name)
of ____________________ (address)
[PRINT NAME AND ADDRESS OF YOUR AGENT]
do hereby designate and appoint ____________________(name of agent)
_______________________________(address and telephone number of agent)
as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition.