$23.95

Add to cart

Indiana ___ nd at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ________________________________________________ Date ___________________ City, County and State of Residence ________________________________________________ The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I am competent amedical or surgical treatment and accept the consequences of the request. I understand the full import of this declaration. Signed: ___________________________________________________________________to give directions regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to request dration, the administration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain. In the absence of my ability ave an incurable injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life. This includes appropriate nutrition and hyI, ________________________________________________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that if at any time I h____________________________________________ Date __________________ 2 Life Prolonging Procedures DECLARATION Declaration made this _____________________ day of _____________________ (month, year). ly responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ____eclarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financial_________________________________________________ City, County, and State of Residence The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the d_____________________________________ I understand the full import of this declaration. Signed: _______________________________________________________________________ _______________________________ ____________________________________________________________________________ 1 ____________________________________________________________________________ _______________________________________he refusal. Additional Instructions (optional): ____________________________________________________________________________ __________________________________________________________________________dures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of te representative appointed under IC 16-361-7 or my attorney in fact with health care powers under IC 30-5-5. In the absence of my ability to give directions regarding the use of life prolonging proce to sustain life is futile or excessively burdensome to me. __________ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health carnutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me. __________ I do not wish to receive artificially supplied nutrition and hydration, if the effortovision of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration): __________ I wish to receive artificially supplied to die naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the pra short time; and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted the circumstances set forth below, and I declare: If at any time my attending physician certifies in writing that: (1) I have an incurable injury, disease, or illness; (2) my death will occur within __________________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged underclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ______________________________ling with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disstarting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dear legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a rocedures withheld or withdrawn. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to theiation unless the person had actual knowledge of the revocation. (d) The revocation of a life prolonging procedures will declaration is not evidence that the declarant desires to have life prolonging p expression of intent to revoke. (b) A revocation is effective when communicated to the attending physician. (c) No civil or criminal liability is imposed upon a person for failure to act upon a revocollowing: (1) A signed, dated writing. (2) Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction. (3) An oralation or life prolonging procedures will declaration Sec. 12. (a) A living will declaration or a life prolonging procedures will declaration may be revoked at any time by the declarant by any of the fific directions. The invalidity of any additional, specific directions does not affect the validity of the declaration. As added by P.L.2-1993, SEC.19. IC 16-36-4-12 - Revocation of living will declar36-4-9 - Forms of declaration; requisites Sec. 9. A declaration must be substantially in the form set forth in either section 10 or 11 of this chapter, but the declaration may include additional, specnt. (g) A life prolonging procedures will declaration under section 11 of this chapter does require the physician to use life prolonging procedures as requested. As added by P.L.2-1993, SEC.19. IC 16-se, withholding, or withdrawal of life prolonging procedures under this chapter; and (2) shall be given great weight by the physician in determining the intent of the patient who is mentally incompetetion under section 10 of this chapter: (1) does not require the physician to use, withhold, or withdraw life prolonging procedures but is presumptive evidence of the patient's desires concerning the uphysician Living Will Information & Instructions ­ Page 3 who is notified shall make the declaration or a copy of the declaration a part of the declarant's medical records. (f) A living will declarae person's pregnancy. (e) The life prolonging procedures will declarant or the living will declarant shall notify the declarant's attending physician of the existence of the declaration. An attending personal representative or as the attorney for the estate in the declarant's will. (d) The living will declaration of a person diagnosed as pregnant by the attending physician has no effect during thponsible for the declarant's medical care. For the purposes of subdivision (3), a person is not considered to be entitled to any part of the declarant's estate solely by virtue of being nominated as astate whether the declarant dies testate or intestate, including whether the witness could take from the declarant's estate if the declarant's will is declared invalid. (4) Be directly financially ress: (1) Be the person who signed the declaration on behalf of and at the direction of the declarant. (2) Be a parent, spouse, or child of the declarant. (3) Be entitled to any part of the declarant's eence of at least two (2) competent witnesses who are at least eighteen (18) years of age. (c) A witness to a living will declaration under subsection (b)(5) may not meet any of the following condition(2) Be in writing. (3) Be signed by the person making the declaration or by another person in the declarant's presence and at the declarant's express direction. (4) Be dated. (5) Be signed in the presection 11 of this chapter or a living will declaration under section 10 of this chapter. (b) A declaration under section 10 or 11 of this chapter must meet the following conditions: (1) Be voluntary. dures will declarations; living will declarations Sec. 8. (a) A person who is of sound mind and is at least eighteen (18) years of age may execute a life prolonging procedures will declaration under se provider for the failure to provide medical treatment to a patient who has refused the treatment in accordance with this section. As added by P.L.2-1993, SEC.19. IC 16-36-4-8 - Life prolonging proce. (b) No health care provider is required to provide medical treatme nt to a patient who has refused medical treatment under this section. (c) No civil or criminal liability is imposed on a health carunity from liability for failure to treat patient after refusal of treatment Sec. 7. (a) A competent person may consent to or refuse consent for medical treatment, including life prolonging proceduresical or surgical means or procedures calculated to prolong the competent adult's life provided, withheld, or withdrawn. As added by P.L.2-1993, SEC.19. IC 16-36-4-7 - Consent to medical treatment; imms added by P.L.2-1993, SEC.19. IC 16-36-4-6 - Policy Sec. 6. A competent adult has the right to control the decisions relating to the competent adult's medical care, including the decision to have medno recovery; and (2) death will occur from the terminal condition within a short period of time without the provision of life prolonging procedures. Living Will Information & Instructions ­ Page 2 Andition defined Sec. 5. As used in this chapter, "terminal condition" means a condition caused by injury, disease, or illness from which, to a reasonable degree of medical certainty: (1) there can be As used in this chapter, "qualified patient" means a patient who has been certified as a qualified patient under section 13 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-5 - Terminal coer, "living will declarant" means a person who has executed a living will declaration under section 10 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-4 - Qualified patient defined Sec. 4. has executed a life prolonging procedures will declaration under section 11 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-3 - Living will declarant defined Sec. 3. As used in this chapt SEC.19. Amended by P.L.99-1994, SEC.1. IC 16-36-4-2 - Life prolonging procedures will declarant defined Sec. 2. As used in this chapter, "life prolonging procedures will declarant" means a person whoong the dying process. (b) The term does not include the performance or provision of any medical procedure or medication necessary to provide comfort care or to alleviate pain. As added by P.L.2-1993,re" means any medical procedure, treatment, or intervention that does the following: (1) Uses mechanical or other artificial means to sustain, restore, or supplant a vital function. (2) Serves to prollating to Living Wills. IC 16-36-4 Chapter 4. Living Wills and Life Prolonging Procedures IC 16-36-4-1 - Life prolonging procedure defined Sec. 1. (a) As used in this chapter, "life prolonging proceduLife Prolonging Declaration. This Indiana Living Will is based on Indiana Code Title 16-36 Chapter 4 Section 1 et. Seq. For your convenience, we have included useful excerpts from the Indiana Codes retructions Indiana Living Will & Life Prolonging Declaration This package contains (1) Information and Instruction for Indiana Living Will and Life Prolonging Declaration; (2) Indiana Living Will; (3) ______________, the principal, this _____ day of __________________, 20____. ______________________________________ (Notary Public) My Commission expires __________________ -2- Information and Insen years of age or older, of sound mind, and under no constraint or undue influence. ___________________________________ (Principal) Subscribed and acknowledged before me by _____________________________________ 20 _____, and do hereby declare to the undersigned witness that I sign it willingly, and I execute it as my free and voluntary act for the purposes herein expressed, and that I am eighteng of nutrition and hydration through intravenous, gastrostomy or nasogastric tubes.. I, ___________________________________, the principal, sign my name to this instrument this _______ day of ______-1- I understand health care to include any medical care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental well-being, and also includes the providi physicians and other relevant health care givers. To the extent appropriate, my health care representative may also discuss this decision with my family and others to the extent they are available. representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representative may make such a decision for me, after consultation with my physician ormay express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result. My health care y health care representative is satisfied that certain health care is not or would not be beneficial or that such health care is or would be excessively burdensome, then my health care representative representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time based on my previously expressed preferences and the diagnosis and prognosis mome telephone number) _________________ (work telephone number) Appointment of my Attorney- in-Fact as my Health Care Representative In addition to the powers granted above, I authorize my health careneyin- fact, I hereby appoint: __________________________________________________ (name of successor attorney- in- fact) of _____________________________________________ (address) _________________ (hmical gifts on my behalf; (5) to request an autopsy; and (6) to make plans for the disposition of my body In the event the person I appoint above is unable, unwilling or unavailable to act as my attorre providers to care for me; (2) to admit or release me from a hospital or health care facility; (3) to have access to my records, including medical records, concerning my condition; (4) to make anatoapable of making my own health care decisions. I grant my attorney- in- fact the following powers in matters affecting my health care: (1) to employ or contract with servants, companions, or health ca____________________ (address) _________________ (home telephone number) _________________ (work telephone number) as my attorney- in- fact to make health care decisions on my behalf whenever I am inc (address) being of sound mind, willfully and voluntarily appoint hereby appoint _________________________________________________ (name of attorney- in-fact) _________________________________________e found at findlegalforms.com -4- Power of Attorney for Health Care I, _________________________________________________________ (name) of ___________________________________________________________rty. Any -3- possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another pa and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before usrranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legale recorded; and (2) reference the book and page or instrument number where the instrument creating the power of attorney is recorded. [_] These forms are provided "as is" and no implied or express wass the attorney in fact or other person has actual knowledge of the revocation. (c) If an executed power of attorney was recorded under IC 30-5-3-3, the revocation of the power of attorney must: (1) be revoked only by a written instrument of revocation that: (1) identifies the power of attorney revoked; and (2) is signed by the principal. (b) A revocation under subsection (a) is not effective unleof the principal, a term of the contract notwithstanding. IC 30-5-10-1 Revocation of power; record Sec. 1. (a) Except as otherwise stated in the power of attorney, an executed power of attorney may bis not a suicide or homicide for any purpose under a statute or rule of law and does not impair or invalidate an insurance, annuity, or other type of contract that is conditioned on the life or death ipline for failure to comply with the attorney in fact. (3) If the principal's death results from withholding or withdrawing health care in accordance with the terms of a power of attorney, the death sonable medical standards at the time of reference and the provider promptly transfers the principal to another health care provider, the provider is not subject to civil or criminal liability or disc if death or injury to the principal results. (2) If the actions of a health care provider who fails to comply with a direction or decision of the attorney in fact are substantially in accord with rea) A health care provider or other person is not subject to civil or criminal liability or discipline for unprofessional conduct for complying with a direction or decision by the attorney in fact, evenrectly with the principal as a fully competent person. In addition, the following rules shall be applied to protect and validate the acts of the attorney in fact and provider or other person: -2- (1e terms of the power of attorney is protected and released from liability to the same extent as the provider or other person would be protected or released if the provider or other person had dealt diion or decision of attorney in fact Sec. 10. A health care provider or other person who acts in good faith reliance on a direction or decision of an attorney in fact that is not clearly contrary to thssary decisions. Each person to whom the attorney in fact communicates a direction shall comply with the direction. IC 30-5-9-10 Health care providers; persons acting in good faith reliance on directe disposition of the principal's remains; the anatomical gift, autopsy, or remains disposition shall be considered the act of the principal or of the person who has priority under law to make the neceosition Sec. 6. If a power of attorney authorizes the attorney in fact to: (1) make an anatomical gift on behalf of the principal; (2) authorize an autopsy of the principal's remains; or (3) direct thhis decision with my family and others to the extent they are available. (b) Nothing in this section may be construed to authorize euthanasia. IC 30-5-7-6 Anatomical gifts, autopsies, or remains dispe may make such a decision for me, after consultation with my physician or physicians and other relevant health care givers. To the extent appropriate, my health care representative may also discuss t discontinued or not instituted, even if death may result. My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representativis or would be excessively burdensome, then my health care representative may express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care bed on my previously expressed preferences and the diagnosis and prognosis my health care representative is satisfied that certain health care is not or would not be beneficial or that such health care in substantially the same form set forth below: I authorize my health care representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time base outweighed by the demands of the treatment and death may result. To empower the attorney in fact to act under this section, the following language must be included in an appointment under IC 16-36-1 ction 16(2) of this chapter, the attorney in fact may be empowered to ask in the name of the principal for health care to be withdrawn or withheld when it is not beneficial or -1- when any benefit isans fo r the disposition of the principal's body. IC 30-5-5-17 Consent to or refusal of health care Sec. 17. (a) If the attorney in fact has the authority to consent to or refuse health care under selth care facility. (4) Have access to records, including medical records, concerning the principal's condition. (5) Make anatomical gifts on the principal's behalf. (6) Request an autopsy. (7) Make pl 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. (3) Admit or release the principal from a hospital or hea with servants, companions, or health care providers to care for the principal. (2) If the attorney in fact is an individual, consent to or refuse health care for the principal who is an individual indual requiring health care. (b) Language conferring general authority with respect to health care powers means the principal authorizes the attorney in fact to do the following: (1) Employ or contractable of consenting to the individual's own health care or to the health care of another from consenting to health care administered in good faith under the religious tenets and practices of the indiviom the Indiana Statutes relating to the Indiana Power of Attorney for Health Care Form. IC 30-5-5-16 Health care powers; religious tenets Sec. 16. (a) This section does not prohibit an individual capna Power of Attorney for Health Care Form. This Indiana Power of Attorney for Health Care is based on Title 30 Chapter 5 Section 30-5-5-16 of the Indiana Statutes. The following are useful excerpts frindlegalforms.com Information and Instructions Indiana Power of Attorney for Health Care This package contains (1) Information and Instruction for Indiana Power of Attorney for Health Care; (2) Indiay possible tax conseque nces arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at f be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Anese forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should notThese forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]Thlth Care Directive. This package also includes the Indiana Life Prolonging Procedures Declaration. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] Indiana Advance Health Care Directive This package contains both a Indiana Power of Attorney for Health Care and a Indiana Living Will. Together these forms are also sometimes known as an Advance Hea Indiana