Health Powers of Attorney Form: Created 1/15/09 Page 1 of 1
HEALTH POWERS OF ATTORNEY FORM FOR INDIANA RESIDENTS
_____________________________________________________(Insert your name and address as principal)
____________________________________________________(Insert name and address of the person appointed)
as my agent (attorney-in-fact) to act for me in any lawful way with respect to the Health Care Powers that may
include acting as my agent with respect to mental health and addictions treatment services, as defined and described
in the Annotated Indiana Code, which is incorporated by reference herein:
Health care powers. (Indiana Code § 30-5-5-16)
Sec. 16. (a) This section does not prohibit an individual capable 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
individual 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 contract 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 in 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 health 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 plans for the disposition of the principal's body.
If you wish your agent to be able to withdraw or withhold health care or to be able to access and discuss treatment
information specific to mental health and/or alcohol or drug treatment as described below, check the respective
I authorize my health care representative to make decisions in my best interest concerning withdrawal or
withholding of health care (pursuant to Ann. Ind. Code §§ 30-5-5-17, 16-31-1, and 16-36-4). If at any time based 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 is 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 be discontinued or not instituted, even if death may result.
I authorize my health care representative to access/receive specially protected treatment information and to
discuss such information with health care providers to coordinate my care for the initialed areas below.
__ Mental Health Records (IC 16-39-2-9) __ Drug and Alcohol Records (CFR 42 Part II)
__ HIV/AIDS Records (IC 16-41-8) __ Infectious Disease Records (IC 16-41-8)
My heath care representative must try to discuss care decisions 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 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.