Free Indiana Medical Power of Attorney Form | PDF | Word

Indiana Medical Power of Attorney Form

An Indiana Medical Power of Attorney, or as the state calls it, the “Appointment of Health Care Representative,” is summed up in its name. When someone becomes incapacitated (can no longer make decisions on their own) and doesn’t have a POA in place, it can make it complicated as to who will be designated as the healthcare decision-maker.

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Last updated October 23rd, 2024

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An Indiana Medical Power of Attorney, or as the state calls it, the “Appointment of Health Care Representative,” is summed up in its name. When someone becomes incapacitated (can no longer make decisions on their own) and doesn’t have a POA in place, it can make it complicated as to who will be designated as the healthcare decision-maker.

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Other Versions (4)

Indiana University Health Version (also available in Spanish/en Español)

Download: Adobe PDF

 

 

 

Reid Health Version

Download: Adobe PDF

 

 

 

Spanish/Español Version

Download: Adobe PDF, MS Word (.docx)
Information: Adobe PDF

 

 

Woodlawn Hospital Version

Download: Adobe PDF

 

 

 

Additional Resources

Related Forms (6)

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Durable (Financial) Power of Attorney

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DNR Order (Form 49559)

Download: Adobe PDF
Laws: § 16-36-5

 

 

Life-Prolonging Procedures Declaration (Form 55315)

Download: Adobe PDF, MS Word (.docx)
IUH Version: Adobe PDF
Spanish Version: Adobe PDF
Laws: § 16-36-4-11

 

Organ Donation Form

Download: Adobe PDF

 

 

 

Physician Orders for Scope of Treatment – POST (Form 55317)

Download: Adobe PDF, MS Word (.docx)
Laws: § 16-36-6

 

 

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