Free Fillable Indiana Medical Power of Attorney Form

Filling out the Indiana Medical POA

Creating an Indiana medical power of attorney form is a simple exercise that any adult can complete. You need to fill out specific details in the sections provided on the form. Below are the steps to guide you on how to write this POA form:

Obtain the POA Form

The first step is to download the power of attorney document from our site in your preferred format. Whether you want it in PDF, ODT, or Word format, ensure that it is similar to the one provided by Indiana state.

Stipulate the Principal’s Particulars

This section, also known as the “Patient/Appointer information,” has a table where the principal must fill out their particulars. The patient, in this case, is the principal. Indicate your last, first, and middle name, your birth date, a medical record number, and the hospital. However, the medical and hospital details are optional for the principal.

Give an Appointment Review

This section consists of a declaration statement from the principal indicating crucial medical instructions. However, you must thoroughly review this section to avoid confusion on the Form 56184. It explains the responsibilities of both the patient and the representative and their limitations.

Here, you must state all your treatment preferences that your health care agent will execute when you suffer incapacitation.

List Powers and Limitations

After reviewing the document and filling out the principal’s particulars, you can now list all the powers you want to assign the healthcare agent. Include all your treatment preferences and what you want the agent to do in particular situations. For instance, you can specify the attending physician’s decision when you are in a comatose condition. Or whether to accept or decline a life-prolonging procedure.

You can also state the limits of the power that the agent can’t execute. It helps to prevent conflict of interest between doctors, relatives, and the agent. Ensure that you indicate when the power of attorney agreement will take effect. For instance, if you suffer incapacitation and can’t communicate.

Appoint a Health Care Agent

During completion of this POA form, you must choose a reliable health care agent who is willing to take up the responsibility of handling your medical affairs. Before writing their name on the POA form, you need to inform the individual so that they confirm the voluntary assumption of an agent’s role.

Fill out the agent’s particulars on the form, such as full name, physical address, and working telephone number.

Signatures and Witness Information

Finally, ensure that you add your signature and the current date on the form. Not forgetting to include the witness particulars and signature.