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The Indiana Medical Power of Attorney, or as the state refers to it, the “Appointment of Health Care Representative”, is basically summed up in its title. When someone becomes incapacitated (can no longer make decisions on their own) and doesn’t have a POA in place, it can make it complicated as to who will be designated as the healthcare decision-maker. By accomplishing this form in advance, you can personally assign this task to whoever you deem has your best interest. To secure an operable POA, be prepared to supply the form with personal details regarding you and your agent, specify any additional terms & conditions, and furnish it with your written (or electronic) signature in the presence of a competent witness.
Laws
Statutes – § 16-36-1
Definition – A “representative” is an individual at least eighteen (18) years of age appointed to consent to the health care of another under this chapter (§ 16-36-1-2).
Signing Requirements – Appointor’s execution of the instrument must be witnessed by an adult (§ 16-36-1-6(a)(3)).
Other Versions (4)
Indiana University Health Version (also available in Spanish/en Español)
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF, MS Word (.docx)
Information: Adobe PDF
Download: Adobe PDF
Additional Resources
- Indiana State Department of Health – Advance Directive Information
- Indiana State Department of Health – Medical Power of Attorney Instructions
Related Forms (6)
- Advance Directive (Medical POA & Living Will)
- DNR Order (Form 49559)
- Durable (Financial) Power of Attorney
- Life-Prolonging Procedures Declaration (Form 55315)
- Organ Donation Form
- Physician Orders for Scope of Treatment – POST (Form 55317)
Advance Directive (Medical POA & Living Will)
Download: Adobe PDF, MS Word (.docx)
Durable (Financial) Power of Attorney
Download: Adobe PDF, MS Word (.docx)
DNR Order (Form 49559)
Download: Adobe PDF
Laws: § 16-36-5
Life-Prolonging Procedures Declaration (Form 55315)
Download: Adobe PDF, MS Word (.docx)
IUH Version: Adobe PDF
Spanish Version: Adobe PDF
Laws: § 16-36-4-11
Download: Adobe PDF
Physician Orders for Scope of Treatment – POST (Form 55317)
Download: Adobe PDF, MS Word (.docx)
Laws: § 16-36-6
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