Power of AttorneyForms & guidance
Find a form ↗

Kentucky Health Care Surrogate and Living Will Form

Names a health care surrogate and backup for loss of decisional capacity, with separate treatment and organ-donation choices.

Jurisdiction
Kentucky
Purpose
Medical & health care
Source / form version
No revision date printed on the health system’s form.
Resource format
PDF
Signing
Sign and date with two qualified adult witnesses together in the principal’s presence, OR acknowledge before a qualified notary. Read KRS 311.625 witness/notary conflict restrictions.
Preview PDF

Open the preview to load the complete document. If it does not display, use the direct link below.

Open PDF in a new tab (opens in a new tab)

Sources checked: 2026-11-13. General information, not individual legal advice.

Make the surrogate appointment explicitly

Norton’s one-page form places the health care surrogate designation at the top. Enter your name, the first surrogate, and the backup, then initial the appointment choice. The adjacent no-election option does not appoint a person. Discuss the role with the people you name, including how they should communicate your wishes if you cannot decide.

Sources: [1] [3] [4] [5]

Read the alternatives across each row

The form uses separate rows for life-prolonging treatment, artificial nutrition and hydration, and organ donation. Select the alternative that reflects your decision within each row rather than initialing conflicting choices. The surrogate-discretion options differ from an instruction requiring treatment or withholding it. Ask a clinician to explain unfamiliar treatment language before signing.

Sources: [1] [3] [4] [5]

Use an eligible signing method

Kentucky permits two eligible adult witnesses or a notary. The restrictions include blood relatives, statutory heirs, the attending physician, and persons directly responsible for medical costs; a facility employee has a specific notary exception. This hospital form preprints Jefferson County in its notary block. If acknowledging elsewhere, arrange an accurate acknowledgment with the notary. Give complete signed copies to the surrogate, backup, and care team.

Sources: [1] [3] [4] [5]

Common questions

Is the treatment section required to appoint a surrogate?

The form separates the appointment from treatment directions and provides no-election choices. Complete the appointment and execution carefully if choosing an agent is your main purpose.

Sources: [1] [3] [4] [5]

Is this a financial power of attorney?

No. The surrogate and living-will form concerns health care. Consider Kentucky’s separate financial statutory form for banking, property, and financial decisions.

Sources: [1] [3] [4] [5]

Related forms and guides

Sources and verification

  1. Norton Healthcare: source and instructions (opens in a new tab)
  2. Direct PDF (opens in a new tab)
  3. Kentucky Attorney General — living wills and surrogates (opens in a new tab)
  4. Kentucky KRS Chapter 311 — official law (opens in a new tab)
  5. KRS 311.625 — form and execution, code mirror (opens in a new tab)

HTTP 200 direct PDF and publisher page with standard browser user agent. One page, no AcroForm fields, 34071 bytes; entire rendered landscape page inspected. Replaces AG PDF whose scripted retrieval was 403. CaringInfo alternative was inspected but not selected because it still refers to repealed organ-donation §311.185. Norton’s preprinted Jefferson County venue is disclosed. No rehosting or legal-review claim.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.