Free Indiana Medical Power of Attorney Form

Looking for a guide that is not tied to one state? Read our general medical power of attorney form overview. More Indiana documents are listed in the Indiana power of attorney forms category.

The FormsPal template is titled Indiana Medical Power of Attorney with Advance Directive. Part I appoints your agent, also called an attorney-in-fact, and lists the health care powers the agent receives. Part II is an advance directive and Part III holds general provisions. The powers in Part I include:

• Consenting or refusing consent to medical care
• Employing health care personnel
• Gaining access to medical records and other personal information
• Refusing extreme life-prolonging procedures and arranging pain relief
• Decisions about blood transfusions, organ transplants and organ donations
• Arranging the disposition of remains and making personal care decisions

Many people complete a medical POA before surgery or other planned treatment, so a trusted person can speak for them if they cannot.

Indiana Medical Power of Attorney Laws and Requirements

The Indiana power of attorney requirements for a medical POA start with the signing rule. The principal signs in front of two adult witnesses or in front of a notary. At least one of the two witnesses cannot be the principal's spouse or other relative.^[1]

Signed by the declarant in the presence of two (2) adult witnesses or in the presence of a notarial officer.

Here is what that means for an Indiana medical POA, point by point:

• Who signs. The principal, whom the statute calls the declarant, must sign the document in the presence of two adult witnesses or in the presence of a notarial officer.^[1]
• Two witnesses. A document signed before witnesses needs two adult witnesses, and they sign in the principal's presence.^[1]
• Relatives. At least one of the two witnesses may not be the spouse or other relative of the declarant.^[1]
• A notary instead. The declarant may sign or acknowledge the document in the presence of a notarial officer instead of using witnesses. The notary completes and signs a notarial certificate under Ind. Code 33-42-9-12 and makes it a part of the advance directive.^[1]
• Signing for the principal. An individual who signs the declarant's name on the advance directive may not be a witness, the notarial officer, or a health care representative designated in the advance directive.^[1]

Indiana law calls your agent a health care representative. Under Ind. Code § 16-36-7-28(a)(1), your advance directive may designate one or more competent adult individuals or other persons as your health care representative, to make health care decisions for you, to receive health information on your behalf, or both.^[1]

Indiana Medical Power of Attorney Form Details

Filling Out the Indiana Medical Power of Attorney Form

The FormsPal template has blanks on only a few pages. Page 1 asks for the principal, the agent and an alternate agent. Page 6 has the date and the principal's signature, and page 7 has the notary acknowledgment. Build the form online or download the PDF, then work through these steps in order.

The screenshots under each step show the FormsPal Indiana medical power of attorney template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. Name the principal and the agent. On page 1, write your name and address, then the name and address of the agent you appoint. The agent is the person who makes health care decisions for you.

   

2. Add contact details and the alternate agent. Still on page 1, fill in the agent's phone number, email and alternative contact information. Then add the alternate agent's name, address and contact details. The alternate agent acts if the first agent resigns, dies, or is unable or unwilling to act. Pages 2 to 5 are printed text with nothing to fill in.

   

3. Date and sign the document. On page 6, write the date on the line after "I have hereunto set my hand on". Then sign and print your name. Sign only when your witnesses or your notary are with you, as the next section explains.

   

4. Complete the notary acknowledgment. Page 7 is the notary acknowledgment. It has lines for the county, the date, the name and title of the officer, and the principal's name. Complete these lines with your notary.

   

5. Notary signature and seal. The notary signs the "Signature (Seal)" line at the bottom of page 7 and adds the seal.

   

How to Sign and Use the Indiana Medical Power of Attorney

After you fill in the blanks, you sign the form in front of two adult witnesses or a notary.^[1] Then you keep the original safe and share copies with the people who will need them. The steps below cover the whole process in order.

1. Build or download the template. Create the form with the FormsPal online builder at the top of this page, or download the PDF and fill it in by hand.
2. Read the printed pages. Pages 2 to 5 hold the powers, the advance directive and the general provisions. Read them before you sign, and ask a lawyer or your doctor if anything is unclear.
3. Choose your signing route. Decide between two adult witnesses and a notary. If you choose witnesses, at least one of them cannot be your spouse or other relative.^[1]
4. Sign in front of your witnesses or notary. The witnesses sign in your presence. With a notary, the notary completes and signs a notarial certificate and makes it a part of the document.^[1]
5. Keep the original and share copies. The form says only one original is signed and that the agent may make photocopies. Store the original where your agent can find it, and give your agent, your alternate agent and your doctor a copy.

A medical power of attorney works alongside other health care documents. Many Indiana residents also prepare an Indiana living will or an Indiana DNR form, and a durable power of attorney covers financial matters.

Frequently Asked Questions

Does a medical power of attorney need to be notarized in Indiana?

Not if two adult witnesses watch you sign. Indiana lets the principal sign in front of a notary instead of using witnesses. The notary completes and signs a notarial certificate and makes it a part of the document.^[1]

How many witnesses do you need for a medical power of attorney in Indiana?

You need at least two adult witnesses when you do not use a notary. The principal signs, and the two witnesses sign in the principal's presence.^[1]

Can a relative be a witness on an Indiana medical POA?

For one of the two witnesses, yes. At least one of the two adult witnesses may not be the principal's spouse or other relative.^[1]

Can the person who signs for the principal be a witness, notary or agent?

No. An individual who signs the principal's name on the document may not be a witness, the notary, or the health care representative named in it.^[1]

Other Indiana Forms
We provide a range of key Indiana templates to anybody striving for convenience when dealing with various agreements, contracts, and other paperwork.

• Indiana Last Will
• Indiana Living Will
• Indiana Small Estate Affidavit
• Indiana Bill of Sale
• Indiana Rental Lease Agreement
• Indiana Eviction Notice

Download a Free Indiana Medical Power of Attorney Form

Create your Indiana medical power of attorney form online with the FormsPal builder, or download the PDF with 21 fillable fields. Fill it in, print it, and sign it in front of your two adult witnesses or your notary.^[1]

Create a free high quality Indiana Medical Power of Attorney online now!

Create and Print Online Now

General information, not legal or tax advice.

Sources

1. Ind. Code § 16-36-7-28.

Mara Erlach

Writer & Attorney

Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.