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COMBINED DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND HEALTH CARE REPRESENTATIVE APPOINTMENT
. DESIGNATION OF HEALTH CARE AGENT. I, , appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Attorney-in-Fact and Health Care Representative ("Agent") to make any and all health care decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way.
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests.
. DURATION. The appointment of my Health Care Agent does not commence until I am incapable of consenting to health care treatment, and such appointment is not effective if I later become capable of consenting.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. GENERAL PROVISIONS.
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES AND A NOTARY PUBLIC)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on ______ day of ____________________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
has been personally known to me and I believe him/her to be of sound mind. I did not sign 's signature above for or at the direction of . I am not a parent, spouse, or child of . I am not entitled to any part of 's estate or directly financially responsible for 's medical care. I am competent and at least eighteen (18) years old.
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
State of _________________________,
County of _________________________ ss:
On this _____ day of ____________________, _____, , known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document.
My commission expires: _________________________
________________________________________
Notary Public
NOTICE TO ATTORNEY-IN-FACT
The Attorney-in-Fact shall ascertain whether has notified 's health care providers that a power of attorney has been executed. If has not notified 's health care providers of the existence of a power of attorney, the Attorney-in-Fact shall notify the health care providers of the existence of the power of attorney.
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It is fast and simple to assign or receive the authority you may need using a free Indiana Medical Power of Attorney template from Rocket Lawyer:
This route, in most cases, would be notably more affordable and convenient than finding and hiring your average lawyer. If needed, you can start a Medical PoA on behalf of a family member, and then have that person sign it after you've drafted it. Please note that for a Power of Attorney to be considered legally valid, the principal must be mentally competent when they sign. In the event that the principal is already unable to make their own decisions, a court-appointed conservatorship may be required. When managing such a situation, it is a good idea to work with a lawyer .
Anyone who is over 18 ought to have a Medical Power of Attorney. Though it can be painful to think about, there could come a time when you are no longer able to make your own healthcare decisions. Typical circumstances in which you may consider PoA forms to be useful include:
Regardless of whether your Indiana Medical Power of Attorney has been drafted as part of a forward-looking plan or created in response to an unexpected issue, notarization and witnesses will often help to protect your document if its credibility is questioned.
In researching the topics of estate planning or elder care, you or a loved one might see the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used interchangeably. At the end of the day, they're one and the same. That being said, you should keep in mind that it's entirely possible to give power of attorney over affairs that are not health-related, in which case, "proxy" usually is not the preferred term.
Indiana Medical PoA forms are typically straightforward, but you or your agent(s) could have legal questions. It can depend on whom you reach out to, but quite often some lawyers will not even accept requests to review documents that they did not work on. A better approach to consider is to get help via attorney services at Rocket Lawyer. When you become a Premium member, you have the ability to request a document review from an experienced lawyer or pose additional questions related to your Medical Power of Attorney. As always, Rocket Lawyer is here to help.
The cost of finding and working with a law firm to draft a Medical Power of Attorney can add up to anywhere between two hundred and five hundred dollars, depending on your location. Unlike many other sites that you might come across, Rocket Lawyer offers more than a Power of Attorney template. If you ever require support from a lawyer, your Premium membership provides up to 40% in savings when you hire an attorney.
After completing your document using Rocket Lawyer, you will have the ability to review it anytime and anywhere. With a Premium membership, you can edit it, print it out, and/or sign it. Attached to your Power of Attorney, there will be a checklist of tips on what's next after your document is finished. You will need to provide a copy of your signed document to your agent(s) and care providers.
The specific rules and restrictions governing PoA forms will be different by state; however, in Indiana, your document will need notarization.
See Indiana Medical/Healthcare Power of Attorney law: IC 16-36-1
