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Indiana Health Care Power of Attorney Form

The Indiana health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Indiana Health Care Power of Attorney Form
Indiana Health Care Power of Attorney Form
INSTRUCTIONS
PRINT YOUR
NAME AND
ADDRESS
PRINT THE
NAME,
ADDRESS AND
TELEPHONE
NUMBERS OF
YOUR
ATTORNEY-IN-
FACT
POWERS OF
YOUR
ATTORNEY-IN-
FACT
© 2000
P
ARTNERSHIP FOR
CARING, INC.
INDIANA POWER OF ATTORNEY FOR
HEALTH CARE DECISIONS
AND
APPOINTMENT OF
HEALTH CARE REPRESENTATIVE
1) I, ________________________________________________________
(name)
of __________________________________________________________
(address)
hereby appoint ________________________________________________
(name of attorney-in-fact)
____________________________________________________________
(address)
____________________________________________________________
(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 health 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 involved in my health care;
(2) to admit or release me from a hospital or health care facility;
(3) to have access to my records, including medical records;
(4) to make anatomical gifts on my behalf;
(5) to request an autopsy; and
(6) to make plans for the disposition of my body.
Pr
ovided by:
Indiana Health Care Power of Attorney Form
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