Fillable Printable Health Power of Attorney Form for Residents - Indiana

Health Power of Attorney Form for Residents - Indiana

Health Powers of Attorney Form: Created 1/15/09 Page 1 of 1

HEALTH POWERS OF ATTORNEY FORM FOR INDIANA RESIDENTS

I, ___________________________________________________________________________

_____________________________________________________(Insert your name and address as principal)

appoint ______________________________________________________________________

____________________________________________________(Insert name and address of the person appointed)

as my agent (attorney-in-fact) to act for me in any lawful way with respect to the Health Care Powers that may

include acting as my agent with respect to mental health and addictions treatment services, as defined and described

in the Annotated Indiana Code, which is incorporated by reference herein:

Health care powers. (Indiana Code § 30-5-5-16)

Sec. 16. (a) This section does not prohibit an individual capable of consenting to the individual's own health care or to the

health care of another from consenting to health care administered in good faith under the religious tenets and practices of the

individual requiring health care.

(b) Language conferring general authority with respect to health care powers means the principal authorizes the attorney in

fact to do the following:

(1) Employ or contract with servants, companions, or health care providers to care for the principal.

(2) If the attorney in fact is an individual, consent to or refuse health care for the principal who is an individual in accordance

with IC 16-36-4 and IC 16-36-1 by properly executing and attaching to the power of attorney a declaration or

appointment, or both.

(3) Admit or release the principal from a hospital or health care facility.

(4) Have access to records, including medical records, concerning the principal's condition.

(5) Make anatomical gifts on the principal's behalf.

(6) Request an autopsy.

(7) Make plans for the disposition of the principal's body.

If you wish your agent to be able to withdraw or withhold health care or to be able to access and discuss treatment

information specific to mental health and/or alcohol or drug treatment as described below, check the respective

boxes below:

 I authorize my health care representative to make decisions in my best interest concerning withdrawal or

withholding of health care (pursuant to Ann. Ind. Code §§ 30-5-5-17, 16-31-1, and 16-36-4). If at any time based on

my previously expressed preferences and the diagnosis and prognosis my health care representative is satisfied that

certain health care is not or would not be beneficial or that such health care is or would be excessively burdensome,

then my health care representative may express my will that such health care be withheld or withdrawn and may

consent on my behalf that any or all health care be discontinued or not instituted, even if death may result.

 I authorize my health care representative to access/receive specially protected treatment information and to

discuss such information with health care providers to coordinate my care for the initialed areas below.

__ Mental Health Records (IC 16-39-2-9) __ Drug and Alcohol Records (CFR 42 Part II)

__ HIV/AIDS Records (IC 16-41-8) __ Infectious Disease Records (IC 16-41-8)

My heath care representative must try to discuss care decisions with me. However, if I am unable to communicate,

my health care representative may make such a decision for me, after consultation with my physician or physicians

and other relevant health care givers. To the extent appropriate, my health care representative may also discuss this

decision with my family and others to the extent they are available.

Health Powers of Attorney Form: Created 1/15/09 Page 2 of 2

CHECK ONE OF THE FOLLOWING BOXES:

 This power of attorney shall terminate upon my disability, incapacity or incompetence.

 This power of attorney is effective immediately, and shall not be affected by my disability, incapacity or

incompetence.

 This power of attorney will become effective upon my disability, incapacity or incompetence.

I understand that in accordance with Indiana Code 30-5-10-1, except as otherwise stated in this power of attorney

form, this executed power of attorney may be revoked only in writing wherein the written revocation statement

identifies the power of attorney revoked and is signed by myself, the principal. This power of attorney shall continue

in full force and effect until I have executed and recorded in the Recorder’s Office of the county of my domicile a

written revocation hereof.

Signed this ________ day of _______________, _________.

____________________________________ _____________________________

(Your signature) (Your social security number)

State of __________________. County of ________________.

On this _____________day of ______________________, ________, before me personally appeared

______________________________________ (name of principal), who is personally known to me or provided

______________________________________________as identification, and acknowledged that he or she

executed this health powers of attorney form.

____________________________

Notary Public