Indiana Durable Medical Power of Attorney Form

Indiana Power Of Attorney gives authority to a named person, called the `Agent` via the principal over health care decisions for the principal. This can apply when the principal is so ill that they are no longer able to make these decisions themselves. The document is in accordance with US statutes § 30-5-1-1 to 30-5-5-19. The option for the principal to select their own personal wishes within the agents authorized actions is provided in this Power of Attorney document.

How to Write

Health Power Of Attorney Form For Indiana Residents.

1) The principal must carefully read the document and then complete the required blank fields.

  • Principal`s name.
  • Principal`s address.
  • Agent`s name.
  • Agent`s address.

 

Withdraw & Withhold Treatment & Health Care

The principal must check box to give the health care representative authority over decisions regarding withdrawing and withholding health care and treatment.

 

Authorization Of Information Sharing

The principal must decide how they wish they personal medical information to be shared.

  • The principal must check the box to give their health care representative authority to share protected treatment information with care providers.
  • The principal must check the relevant boxes to denote the specif types of personal medical information they wish to be shared by the health care representative with care providers.

 

Effectiveness Of Power Of Attorney Document

The principal must check the relevant box to denote when the Power Of Attorney Document is effective.

  • Check to terminate power of attorney upon the principal`s disability, incapacity or incompetence.
  • Check to make power of attorney immediately effective and unaltered by disability, incapacity or incompetence.
  • Check box to make power of attorney effective upon the principal`s disability, incapacity or incompetence.

 

Declaration

The principal must enter the personal details of the people authorizing the document.

  • Date.
  • Signature.
  • Social security number.
  • State.
  • County.
  • Date.
  • Principal`s name.
  • Specific proof of identification used if required.
  • Signature of notary.