Indiana Medical Power of Attorney
This Medical Power of Attorney is granted pursuant to the Indiana Health Care Consent Act. It authorizes a designated person (referred to as the "Agent") to make healthcare decisions on behalf of the person granting this power (referred to as the "Principal") when the Principal is unable to make such decisions personally. This document must be completed according to the laws of the State of Indiana and may require notarization for legal validity.
Principal's Information:
- Name: ___________________________
- Date of Birth: ___________________
- Address: _________________________
- Phone Number: ___________________
Agent's Information:
- Name: ___________________________
- Relationship to Principal: ________
- Address: _________________________
- Phone Number: ___________________
By signing this document, the Principal appoints the Agent to make healthcare decisions on the Principal's behalf under the conditions specified herein. This power includes, but is not limited to, consenting to or refusing medical treatment, accessing medical records, and making decisions about the Principal's living arrangements as they pertain to health care. This authority becomes effective when the Principal is determined to be incapable of making healthcare decisions.
Successor Agent's Information (Optional):
- Name: ___________________________
- Relationship to Principal: ________
- Address: _________________________
- Phone Number: ___________________
If the Agent named above is unable, unwilling, or unavailable to act as the Principal's healthcare representative, the Principal designates the above-named Successor Agent to serve instead.
Signature:
- Principal's Signature: ___________________________ Date: __________
- Agent's Signature: _____________________________ Date: __________
- Successor Agent's Signature (If Applicable): _____________________________ Date: __________
- Witness's Signature: _____________________________ Date: __________
This document was signed in the presence of a witness, who is not the Agent or Successor Agent, to validate the Principal's sound mind and voluntary grant of power to the Agent.
Notarization (If Required):
This document was acknowledged before me on the date indicated above by the Principal, who is personally known to me or has produced identification as proof of identity.
Notary Public's Signature: ___________________________
Date: __________
My commission expires: __________
This Medical Power of Attorney shall remain in effect until it is revoked by the Principal or until the Principal's death, whichever occurs first. The Principal may revoke this Power of Attorney at any time by providing written notice to the Agent.
It is recommended that the Principal consult with a healthcare professional and an attorney before completing this document to ensure that it accurately reflects the Principal's wishes and complies with current Indiana law.
