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Indiana _____ day of __________________, 20____. ______________________________________ (Notary Public) My Commission expires __________________ -2- mind, and under no constraint or undue influence. ___________________________________ (Principal) Subscribed and acknowledged before me by ______________________________________, the principal, this by 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 eighteen years of age or older, of sound ugh intravenous, gastrostomy or nasogastric tubes.. I, ___________________________________, the principal, sign my name to this instrument this _______ day of ___________________ 20 _____, and do herenclude any medical care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental well-being, and also includes the providing of nutrition and hydration throlth 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. -1- I understand health care to i 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such a decision for me, after consultation with my physician or physicians and other relevant heath care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result.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 representative must try to discusstisfied 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 may express my will that such healin 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 my health care representative is sa______ (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 care representative to make decisions __________________________________________________ (name of successor attorney-in-fact) of _____________________________________________ (address) _________________ (home telephone number) ___________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 attorneyin-fact, I hereby appoint: 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 anatomical gifts on my behalf; (5) th 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 care providers to care for me; (ess) _________________ (home telephone number) _________________ (work telephone number) as my attorney-in-fact to make health care decisions on my behalf whenever I am incapable of making my own heal mind, willfully and voluntarily appoint hereby appoint _________________________________________________ (name of attorney-in-fact) _____________________________________________________________ (addr.com -4- Power of Attorney for Health Care I, _________________________________________________________ (name) of ___________________________________________________________ (address) being of soundax 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 Use found at findlegalformsent 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 party. Any -3- possible tvary 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 using or signing this documr 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 legal and/or tax advice. Laws rence 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 warranties have been made oor 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 recorded; and (2) refeten 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 unless the attorney in fact m 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 be revoked only by a writicide 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 of the principal, a teromply 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 is not a suicide or homds 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 discipline for failure to cthe 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 reasonable medical standarr 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, even if death or injury to al 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- (1) A health care provide 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 directly with the principrney 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 the terms of the power ofperson 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 direction or decision of attorincipal'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 necessary decisions. Each ower 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 the disposition of the pfamily 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 disposition Sec. 6. If a pision 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 this decision with my 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 representative may make such a decively 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 be discontinued or not pressed 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 is or would be excesssame 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 based on my previously exmands 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 in substantially the hapter, 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 is outweighed by the deion 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 section 16(2) of this c4) 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 plans for the disposit16-36-4 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 health care facility. (anions, 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 in accordance with IC h 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 contract with servants, compo 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 individual requiring healtutes 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 capable of consenting ty 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 from the Indiana StatInformation 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) Indiana Power of Attorne Indiana