Medical Power of Attorney Form for Indiana

INDIANA HEALTH CARE REPRESENTATIVE APPOINTMENT AND MEDICAL POWER OF ATTORNEY

DOCUMENT ID: IN-HCPOA-2026-V1.0
EFFECTIVE DATE: [Effective Date]
GOVERNING JURISDICTION: State of Indiana (Indiana Code § 16-36-1 et seq. and Indiana Code § 30-5 et seq.)

---

1. STATUTORY & LEGAL COMPLIANCE NOTICE

THIS IS A LEGAL DOCUMENT. IT IS GOVERNED BY THE LAWS OF THE STATE OF INDIANA, INCLUDING THE INDIANA HEALTH CARE CONSENT ACT (IND. CODE § 16-36-1) AND THE INDIANA POWERS OF ATTORNEY ACT (IND. CODE § 30-5). THIS INSTRUMENT AUTHORIZES ANOTHER PERSON (YOUR HEALTH CARE REPRESENTATIVE OR ATTORNEY-IN-FACT) TO MAKE MEDICAL TREATMENT DECISIONS FOR YOU IF YOU ARE INCAPACitated, INCOMPETENT, OR OTHERWISE UNABLE TO MAKE OR COMMUNICATE YOUR OWN HEALTH CARE DECISIONS.

BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD CAREFULLY READ AND UNDERSTAND ALL TERMS. IF YOU HAVE ANY QUESTIONS REGARDING THE LEGAL OR CLINICAL IMPLICATIONS OF THIS APPOINTMENT, YOU ARE ADVISED TO CONSULT WITH INDEPENDENT LEGAL COUNSEL AND/OR YOUR ATTENDING PHYSICIAN.

---

2. PARTIES & DECLARATION

This Indiana Health Care Representative Appointment and Medical Power of Attorney is made and entered into on this [Effective Date], by and between:

THE PRINCIPAL:
Name: [Principal Full Legal Name]
Residential Address: [Principal Street Address, City, State, ZIP Code]
Telephone Number: [Principal Telephone Number]
Date of Birth: [Principal Date of Birth]

(Hereinafter referred to as the "Principal").

THE HEALTH CARE REPRESENTATIVE (ATTORNEY-IN-FACT):
Name: [Representative Full Legal Name]
Relationship to Principal: [Relationship, e.g., Spouse, Adult Child, Attorney]
Residential Address: [Representative Street Address, City, State, ZIP Code]
Telephone Number: [Representative Telephone Number]
Email Address: [Representative Email Address]

(Hereinafter referred to as the "Health Care Representative").

SUCCESSOR HEALTH CARE REPRESENTATIVE (ALTERNATE):
In the event that the primary Health Care Representative named above is unwilling, unable, or legally disqualified to serve, the Principal hereby appoints:
Name: [Alternate Representative Full Legal Name]
Relationship to Principal: [Relationship]
Residential Address: [Alternate Street Address, City, State, ZIP Code]
Telephone Number: [Alternate Telephone Number]

---

3. EXHAUSTIVE OPERATIVE CLAUSES & LEGAL TERMS

SECTION 3.1: REVOCATION OF PRIOR APPOINTMENTS

The Principal hereby revokes any prior health care power of attorney, health care representative appointment, living will declaration, or similar medical directive executed by the Principal prior to the date of this document, to the extent that such prior instruments conflict with the provisions set forth herein.

SECTION 3.2: GRANT OF AUTHORITY & SCOPE OF AGENCY

Pursuant to Indiana Code § 16-36-1 and Indiana Code § 30-5, the Principal hereby grants to the Health Care Representative full power and authority to make health care decisions for the Principal as if the Principal were fully competent and acting on their own behalf. This authority shall become effective only upon a determination that the Principal lacks capacity to make health care decisions, as certified in writing by the attending physician in accordance with applicable Indiana law.

The authority granted herein includes, without limitation, the following powers:

1. Consent and Refusal: To consent, refuse to consent, or withdraw consent to any type of health care, medical care, treatment, surgical procedure, diagnostic procedure, medication, or psychological therapy, including the administration of pain-relieving drugs and palliative care.
2. Facility Access and Selection: To select, contract with, admit to, and discharge from any hospital, nursing home, hospice, residential care facility, or other health care institution, and to have full access to all medical records and personal health information protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and applicable Indiana privacy statutes.
3. Physician and Provider Selection: To employ, retain, and discharge physicians, psychiatrists, dentists, nurses, therapists, and other health care professionals.
4. Anatomical Gifts: To authorize anatomical gifts, organ donations, or body donations upon the Principal’s death, subject to any specific written instructions executed by the Principal.
5. Autopsy and Disposition: To authorize post-mortem examinations (autopsies) and direct the disposition of the Principal’s remains, including funeral, burial, or cremation arrangements, consistent with any pre-arranged plans.

SECTION 3.3: LIMITATIONS ON AUTHORITY

Notwithstanding any other provision in this document, the Health Care Representative shall NOT have the authority to consent to any of the following on behalf of the Principal:

1. Abortion, except as strictly necessary to preserve the life of the Principal.
2. Sterilization.
3. Psychosurgery.
4. Admission to a state mental health facility for psychiatric care, except as authorized under applicable Indiana involuntary commitment statutes.
5. Withholding or withdrawal of nutrition and hydration artificially supplied (tube feeding) if such withdrawal would result in death solely by starvation or dehydration, unless the Principal has explicitly authorized such withdrawal in a separate Living Will or Declaration.

SECTION 3.4: STANDARD OF CARE AND GUIDING PRINCIPLES

In exercising the authority granted under this document, the Health Care Representative shall be bound by the following standards:

1. Substituted Judgment: The Health Care Representative shall make decisions based on the known desires, religious beliefs, moral values, and prior statements of the Principal, whether expressed orally or in writing.
2. Best Interests: If the Principal's desires are unknown and cannot be ascertained with reasonable diligence, the Health Care Representative shall make decisions in accordance with the best interests of the Principal, taking into account the preservation of the Principal's life, the alleviation of pain, and the potential for recovery or amelioration of the Principal's medical condition.

SECTION 3.5: HIPAA WAIVER AND MEDICAL INFORMATION ACCESS

The Principal hereby expressly designates the Health Care Representative as a personal representative for all purposes under the Health Insurance Portability and Accountability Act (HIPAA) (45 CFR § 164.502(g)) and all applicable state medical privacy laws. All licensed physicians, hospitals, clinics, psychologists, nursing homes, and other covered entities are authorized to disclose to the Health Care Representative any and all protected health information (PHI), medical charts, diagnostic reports, and billing records upon request, without the necessity of obtaining any further authorization or release from the Principal.

SECTION 3.6: RELIANCE BY THIRD PARTIES

Any health care provider, facility, physician, or other third party who acts in good faith reliance upon any instruction, consent, or directive given by the Health Care Representative shall incur no civil or criminal liability to the Principal, the Principal’s estate, or the Principal’s heirs. Such third parties shall be fully protected and released from any obligation to inquire into the scope of the Health Care Representative's authority or the circumstances surrounding the determination of the Principal’s incapacity.

SECTION 3.7: COMPENSATION AND REIMBURSEMENT

The Health Care Representative shall serve without compensation for services rendered in such capacity. However, the Health Care Representative shall be entitled to prompt reimbursement from the Principal’s estate or assets for all reasonable and necessary out-of-pocket expenses incurred in the performance of duties authorized under this document (including travel, communication, and document reproduction expenses).

SECTION 3.8: DURABILITY AND TERMINATION

This Health Care Representative Appointment and Medical Power of Attorney is durable and shall not be affected by the subsequent disability, incapacity, or lapse of time of the Principal. This document shall remain in full force and effect until revoked by the Principal in writing, or until the death of the Principal, whichever occurs first.

SECTION 3.9: GOVERNING LAW AND JURISDICTION

This document, and all questions concerning its validity, construction, interpretation, and enforcement, shall be governed by, construed, and enforced in accordance with the laws of the State of Indiana, without regard to its conflict of laws principles. The Principal and the Health Care Representative irrevocably submit to the exclusive jurisdiction of the probate courts of the State of Indiana for any legal proceeding arising out of or relating to this instrument.

SECTION 3.10: SEVERABILITY

If any provision of this document is held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other provision herein. This document shall be construed as if the invalid, illegal, or unenforceable provision had never been contained herein, and the remaining provisions shall remain in full force and effect.

---

4. EXECUTION & FORMAL SIGNATURE BLOCKS

DECLARATION OF PRINCIPAL

I, [Principal Full Legal Name], the Principal, being of sound mind and legal capacity, sign my name to this instrument on this [Effective Date], and do hereby declare that I sign and execute this instrument willingly as my free and voluntary act for the purposes therein expressed, and that I am eighteen (18) years of age or older.

PRINCIPAL:
Signature: _____________________________________
Printed Name: [Principal Full Legal Name]
Date: [Date]

---

WITNESS ATTESTATION

We, the undersigned witnesses, each being eighteen (18) years of age or older, hereby certify that the Principal signed this instrument in our presence, that the Principal appeared to be of sound mind and under no duress, fraud, or undue influence, and that neither of us is appointed as the Health Care Representative or Alternate Health Care Representative herein.

WITNESS 1:
Signature: _____________________________________
Printed Name: [Witness 1 Printed Name]
Address: [Witness 1 Address]
Date: [Date]

WITNESS 2:
Signature: _____________________________________
Printed Name: [Witness 2 Printed Name]
Address: [Witness 2 Address]
Date: [Date]

---

ACCEPTANCE BY HEALTH CARE REPRESENTATIVE

I, [Representative Full Legal Name], the designated Health Care Representative, have read this document and accept the appointment as Health Care Representative. I understand my legal duties, fiduciary responsibilities, and the obligation to act in accordance with the Principal's expressed wishes or best interests.

HEALTH CARE REPRESENTATIVE:
Signature: _____________________________________
Printed Name: [Representative Full Legal Name]
Date: [Date]

---

5. STEP-BY-STEP EXECUTION & FILING GUIDE

1. Document Review: Open this document in Microsoft Word, Google Docs, or an equivalent word processor. Locate all bracketed placeholder text (e.g., [Principal Full Legal Name], [Effective Date]) and replace them with accurate, verified factual information. Do not leave any brackets unfilled.
2. Identity and Capacity Verification: Ensure the Principal possesses the requisite legal capacity (sound mind) at the moment of execution. If there is any potential contest regarding capacity, obtain a contemporaneous clinical evaluation from an attending physician.
3. Execution Ceremony: The Principal must sign and date this document in the physical presence of two (2) qualified adult witnesses. Under Indiana law, neither the designated Health Care Representative nor the Alternate Health Care Representative may serve as a witness.
4. Notarization (Recommended): While Indiana law permits witnessing without notarization, having the Principal's signature notarized by a licensed Notary Public provides heightened evidentiary security and facilitates out-of-state recognition.
5. Acceptance Execution: The designated Health Care Representative must sign the Acceptance section to confirm understanding of and agreement to the fiduciary duties imposed by Indiana law.
6. Record Retention and Distribution:
   • Store the original executed document in a secure, accessible location (not a safe deposit box to which access is restricted upon incapacity).
   • Provide certified copies or high-resolution digital copies to the primary Health Care Representative, the Alternate Health Care Representative, the Principal’s primary care physician, and any hospitals or health care systems where the Principal regularly receives treatment.
   • Retain a digital copy in an accessible personal health record repository.