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Indiana Durable Power of Attorney for Health Care and Appointment of Representative Form

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The Indiana Durable Power of Attorney for Health Care and Appointment of Representative Form grants power to a friend or relative pursuant to Indiana Code § 16-36-1, to make health care decisions on your behalf if and when you are incapable of doing so. In this paperwork, you will be referred to as the Principal and the person you elect will be referred to as your Health Care Representative. In addition to delivering the authority the Health Care Representative requires to carry out your wishes, this form allows you to offer a solid documentation of the instructions of your Health Care instructions and preferences as well as provisions for end of life preferences. Generally, putting such directives in writing will remove most ambiguities regarding your Health Care choices provided a complete report of these wishes is supplied This is an important form to have executed before you have surgery or some other scheduled or unscheduled medical procedure where you will be under anesthesia or otherwise incapacitated.

Laws – IC 16-36‌

Living Will – For the creation of a written instrument that gives medical staff your desires/wishes in the event of an incapacitated state with no cure.

Durable (Financial) Power of Attorney – This document enables you to select an agent to make sound financial decisions on your behalf when you are unable to accomplish this yourself.

How to Write

1 – Gather All The Background Information Then Open and Download The Form

This form will require some specific information regarding the Principal, the Principal’s Preferences, and the Health Care Agent being listed. Reporting this information accurately is vital to a successful execution of this form. Once you have organized all required reference materials, open this form using the buttons on the right.

2 – Provide The Requested Information In Part One

The first blank line in this form will require the Full Name of the Principal entered on the blank line labeled “Name.”

Enter the Complete Address of the Principal on the blank line labeled “Address.”

The blank line labeled “Name of Health-Care Representative,” must have the full name of the Agent recorded. Present the Agent’s Complete Address on the next empty space.

Finally, on the line divided by the sections “home telephone number” and “work telephone number” enter the Agent’s up-to-date Phone Numbers.

The line labeled “name of successor health-care representative” will provide an area for the Principal to name a second Agent who will step up to the role only if the first cannot or is unable to. This is optional but highly recommended. If the Principal would like to name such an entity, then enter the First, Middle, and Last Name of the Successor Agent on the line labeled “Name of Successor Health-Care Representative.”

If a Successor Agent is named then you must also report this entity’s Address, Home Telephone Number, and Work Telephone Number.

The next few paragraphs of Part One will deliver some very important information that should be read and comprehended by the Principal. This will define some of the powers and actions available to the Agent. If there are any areas the Principal disagrees with then, he or she should consult a qualified professional (i.e. attorney, physician) as to whether these items should or can be deleted or crossed out. The next area requiring attention, titled “Guidance for my Health-Care Representative,” will supply several blank lines so the Principal may provide instructions regarding his or her Health Care preferences. These may include special considerations, limitations, extensions, or even some facts about the Principal’s beliefs the Attorney-in-Fact should keep in mind when acting on behalf of the Principal. If there is not enough room, the Principal may continue on an attachment but this should be properly labeled and mentioned in this area.

3 – Declare The Wishes Of The Principal In Part Two

Locate the title “Part Two: Declaration.” This will require the direct attention of the Principal. The Principal should enter the Date he or she is reviewing the next section on the blank lines labeled “day,” “month, year” and print his or her Name on the empty space directly below it. 

Now, the Principal must review the statements present. If the Principal agrees with the statement, then he or she should initial the blank line preceding it.

If the Principal wants his or her life prolonged under any circumstance, then he or she should initial the blank line preceding the words “(Life-Prolonging Procedures Declaration).”

If the Principal does not wish his or her life artificially prolonged, then he or she should initial the blank line preceding the term “Living Will Declaration.” If this choice is made, there will be several circumstances that need to be addressed.

If the Principal has chosen not to have his or her life artificially prolonged then, he or she should indicate if receiving nutrition and hydration artificially is acceptable. If it is, the Principal should initial the blank line preceding the words “I wish to receive…”

If artificial nutrition and hydration to prolong life is unacceptable to the Principal, he or she must initial the blank line before the words “I do not wish…

If the Principal has decided not to make this decision and leave it up to the Agent, he or she should initial the blank line preceding the words “I intentionally make no decision…”

Below this, the Principal may make special instructions regarding end-of-life treatment and medical emergencies. Such instructions may be provided below the words “I further declare that…”

4 – Execute This Document In Part Three

In order to make this document an official directive, the Principal will need to sign it. This signing will need to be substantiated by occurring before a Notary Public and Two Witnesses.

First locate the heading “Part Three: Execution.” The Principal must Print his or her Name on the first blank space in the first paragraph.

Then, using the three spaces available after the words “…instrument this,” the Principal should enter the Calendar Day, Month, and Year of Signing.

The Principal should Sign his or her Name on the blank line after the word “Signed.” Then after the words, “City, County, and State of Residence,” the Principal should enter what City, County, and State he or she officially resides in.

The section below this, “Notary,” will only be filled out by the Notary Public providing his or her instructions are followed at the time of Signing.

The next page will have two Witness Statements under the heading “Witness(es).” Each statement will have two blank Witness Signature Lines. Next to these will be a corresponding Date Line. Each Witness must sign one line and enter the Date of Signature below each statement.

5 – The Organ Donation Option

Immediately after the last page of this form is the “Indiana Organ Donation Form.” This is optional. If the Principal does not wish to donate organs/tissues, he or she should initial the blank line preceding the words “I do not want…”

If the Principal already has a written agreement regarding Organ/Tissue Donation, then he or she should initial the second statement and report the “Name of individual/institution” he or she has an agreement within the space provided.

If the Principal does not have a previously existing arrangement and does want to make anatomical gifts, then he or she should initial the blank line preceding the term, “Pursuant to Indiana law.” This choice will require the Principal to indicate if he or she will donate any needed Organs/Parts by initialing the blank space before the words “Any needed organ…” or the Principal may initial the second choice to indicate that only the parts he or she lists may be donated.

If the Principal will make anatomical gifts he or she may also choose the Purpose for such gifts. If the Organ/Tissue Donation may be made for any legal purpose, the first choice must be selected. If the donation should only be made for “Transplant or therapeutic purposes,” the Principal should initial the second choice.

The Principal should print and sign his or her name on the blank lines labeled “Declarant name” and “Declarant signature.” This must be followed by the Date of Signing on the blank line designated “Date.”

Below will be two Witness Statements which must be signed by an appropriate party. That is a disinterested party who has witnessed this signing. This Witness must sign his or her name on the blank line labeled “Witness,” then enter the “Date” he or she signed this document. Below this, the Witness’s Address should be presented.


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