Indiana Medical Power of Attorney
This Medical Power of Attorney is created in accordance with Indiana state laws. It allows you to designate someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ________________________________
- Date of Birth: ________________________
- Address: ______________________________
- City: _________________________________
- State: Indiana
- Zip Code: ____________________________
Agent Information:
- Name: ________________________________
- Relationship to Principal: ______________
- Address: ______________________________
- City: _________________________________
- State: ________________________________
- Zip Code: ____________________________
Instructions:
By signing this document, you authorize your agent to make health care decisions for you. These decisions may include:
- Choosing medical treatments.
- Deciding on surgeries or procedures.
- Accessing your medical records.
- Making decisions about life-sustaining treatments.
Effective Date: This Power of Attorney is effective immediately upon signing, unless you specify otherwise: ______________________________.
Signature:
______________________________ (Principal)
Date: ________________________
Witnesses:
Two witnesses must sign below. They cannot be your agent or related to you.
- Witness 1: _____________________________
- Witness 2: _____________________________
Date: ________________________
Notary Public:
State of Indiana
County of ____________________________
Subscribed and sworn to before me this _____ day of __________, 20__.
______________________________ (Notary Public)
My Commission Expires: ___________________