Indiana Medical Power of Attorney Form

The Indiana medical power of attorney form is a legal document that will be provided by a Principal to allow an Agent to oversee powers pertaining to health care of the Principal while they are ill and/or absent. The Principal shall specify the powers they wish to grant to the delegated Agent. The Agent should care for the health care decisions as if the Principal were available and able to care for their own health care decisions.

This document must be notarized. The Principal may revoke this document as they wish.

How to Write

Step 1 – Principal’s Information –

  • Enter the Principal’s full name
  • Address
  • AND
  • Agent’s full name
  • Address

Step 2 – Health Care Powers  – Indiana Code § 30-5-5-15

  • Employ or contract with servants companions, or health care providers to care for the principal
  • 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
  • Admit or release the principal from a hospital or health care facility
  • Have access to records, including medical records, concerning the principal’s condition
  • Make anatomical gifts on the principal’s behalf
  • Request an autopsy
  • Make plans for the disposition of the principal’s body

Step 2 – If the Principal would wish the 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, check the appropriate boxes on the form.

Step 3 – Signatures – Enter the following:

  • Enter the date of the signature in dd/mm/yyyy format
  • Principal’s Signature
  • Social Security Number
  • State
  • County
  • AND

Once the notary public has recorded the Principal’s Identification and witnessed their signature, the notary public will enter all of the state required information and will affix the official seal