INDIANA HEALTH CARE POWER OF ATTORNEY
(INCLUDING ADVANCE DIRECTIVE & HIPAA AUTHORIZATION)
[// GUIDANCE: Replace every bracketed [PLACEHOLDER] with client-specific information; delete guidance comments before final execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title & Parties
This Health Care Power of Attorney (this “Instrument”) is executed by [FULL LEGAL NAME OF PRINCIPAL], an individual residing at [ADDRESS] (“Principal”), in favor of the individual identified below as “Agent.”
1.2 Recitals
A. Principal desires to appoint an Agent to make health care decisions on Principal’s behalf in the event Principal lacks capacity or elects to have the Agent act.
B. This Instrument is intended to comply with Indiana Code § 30-5-5-16 et seq. (Powers Affecting the Person; Health Care Decisions) and applicable federal privacy regulations, including 45 C.F.R. § 164.508 (HIPAA Authorization).
C. Consideration for this Instrument is the mutual promises herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged.
1.3 Effective Date & Governing Law
This Instrument is effective on the date of the Principal’s signature (“Effective Date”) and is governed by the laws of the State of Indiana (“Governing Law”).
2. DEFINITIONS
For ease of reference, the following capitalized terms shall have the meanings set forth below. Terms defined herein apply throughout this Instrument unless the context clearly requires otherwise.
“Advance Directive” – The end-of-life instructions contained in Section 3.5.
“Agent” – The primary health care representative appointed in Section 3.1.
“Confidential Health Information” – Individually identifiable health information protected under HIPAA.
“Health Care Provider” – Any physician, hospital, clinic, or other person or entity licensed to provide medical treatment.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations.
“Incapacity” – A determination by two qualified physicians, or by one physician and one licensed psychologist, that the Principal is unable to understand or communicate informed health care decisions.
“Successor Agent” – Any alternate representative designated in Section 3.2.
3. OPERATIVE PROVISIONS
3.1 Appointment of Agent
Principal hereby appoints [FULL LEGAL NAME OF AGENT], whose contact information is [PHONE / EMAIL / ADDRESS], as Agent with full authority to make health care decisions on Principal’s behalf consistent with this Instrument and Governing Law.
3.2 Successor Agent(s)
If the Agent is unable or unwilling to act, Principal appoints the following, in the order listed, as Successor Agent(s):
1. [SUCCESSOR AGENT #1 NAME & CONTACT]
2. [SUCCESSOR AGENT #2 NAME & CONTACT]
3.3 Scope of Authority
Subject to the limitations herein, Agent’s authority includes, without limitation:
a. Consenting to, refusing, or withdrawing medical treatment;
b. Admitting or discharging Principal from a health care facility;
c. Hiring and firing health care personnel;
d. Accessing Confidential Health Information and HIPAA-protected records;
e. Authorizing disclosure of medical records to third parties;
f. Executing waivers, consents, and releases for insurance or governmental benefits; and
g. Making anatomical gift decisions and handling remains in accordance with Indiana Code § 29-2-16-1 et seq.
[// GUIDANCE: Add or delete sub-authorities consistent with client intent.]
3.4 Standard of Decision-Making
Agent shall act:
a. In good faith;
b. In the Principal’s best interest;
c. Consistent with any known wishes of Principal; and
d. Consistent with the Advance Directive in Section 3.5.
3.5 Advance Directive – End-of-Life Provisions
If Principal is diagnosed with a terminal condition or is in a persistent vegetative state and is incapacitated, Principal directs as follows (check ONE in each category):
Life-Prolonging Procedures:
☐ Maintain life-prolonging procedures, including artificial nutrition/hydration.
☐ Withhold or withdraw life-prolonging procedures.
Pain Management:
☐ Administer any medication necessary to alleviate pain, even if it may hasten death.
☐ Limit pain medication to doses that do not hasten death.
Organ Donation:
☐ Yes, donate any needed organs/tissues.
☐ Yes, donate organs/tissues for transplant only.
☐ No, do not donate organs/tissues.
[// GUIDANCE: Insert additional instructions as desired. Attach separate schedules if needed.]
3.6 HIPAA Authorization
Principal authorizes any Health Care Provider to disclose Confidential Health Information to Agent and Successor Agent(s) for so long as this Instrument remains in effect, in accordance with 45 C.F.R. § 164.508. This authorization survives Principal’s death to the extent necessary for Agent to carry out post-mortem health-related decisions.
3.7 Duration; Revocation
This Instrument remains effective until revoked. Principal may revoke by:
a. Written revocation executed with the same formalities as this Instrument;
b. Physical destruction of this Instrument with intent to revoke; or
c. Execution of a later-dated health care power of attorney.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal represents and warrants that:
a. Principal is at least eighteen (18) years of age and of sound mind.
b. No other existing directive conflicts with this Instrument.
c. Principal has reviewed this Instrument and understands its legal effect.
4.2 Agent represents and warrants that:
a. Agent is at least eighteen (18) years of age and is not disqualified under Indiana law.
b. Agent accepts the fiduciary obligations herein.
c. Agent is not presently subject to a restraining order prohibiting contact with Principal.
All representations and warranties survive termination of this Instrument with respect to acts taken during its term.
5. COVENANTS & RESTRICTIONS
5.1 Agent Covenants
a. Act in accordance with Section 3.4.
b. Maintain contemporaneous written records of significant health care decisions.
c. Provide copies of such records to Principal’s legal representative upon request.
5.2 Principal Covenants
a. Provide Agent with complete, accurate medical history and insurance information.
b. Inform Agent promptly of any revocation or amendment to this Instrument.
5.3 Restrictions on Agent
Agent may not:
a. Delegate decision-making authority except to a Successor Agent as expressly named;
b. Execute a new power of attorney on Principal’s behalf;
c. Engage in any self-dealing or conversion of Principal’s property.
6. DEFAULT & REMEDIES
6.1 Events of Default
Any of the following constitute a default by Agent:
a. Breach of fiduciary duty or bad-faith conduct;
b. Incapacity, resignation, or death of Agent without acceptance by a Successor Agent;
c. Judicial removal of Agent under applicable law.
6.2 Notice & Cure
Upon written notice of default from Principal, Successor Agent, or an interested person, Agent shall have five (5) days to cure, unless the default is incapable of cure or immediate action is required for Principal’s health.
6.3 Remedies
a. Automatic elevation of the next Successor Agent;
b. Petition to the appropriate state probate court for injunctive relief;
c. Recovery of reasonable attorneys’ fees and costs incurred to enforce this Instrument.
7. RISK ALLOCATION
7.1 Indemnification of Agent
Principal shall indemnify and hold harmless Agent and Successor Agent(s) from any liability, loss, or expense (including reasonable attorneys’ fees) arising from acts performed in good faith and in accordance with this Instrument, except for gross negligence or willful misconduct.
7.2 Limitation of Liability
Agent’s liability to Principal and Principal’s estate is limited to damages arising from Agent’s gross negligence or willful misconduct (“Good Faith Standard”).
7.3 Insurance
[OPTIONAL] Principal shall maintain a liability insurance policy naming Agent as an additional insured for acts undertaken pursuant to this Instrument.
[// GUIDANCE: Delete if not applicable.]
7.4 Force Majeure
Agent shall not be liable for failure to carry out instructions due to events beyond Agent’s reasonable control, including but not limited to natural disasters, acts of war, or systemic health care system failures.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Instrument is governed by and construed under the laws of the State of Indiana.
8.2 Forum Selection
Any action arising under or related to this Instrument shall be brought exclusively in the [NAME OF COUNTY] Probate Court (the “Designated Court”).
8.3 Arbitration
Arbitration is expressly disclaimed and shall not apply.
8.4 Jury Waiver
No jury waiver is provided. All parties retain their constitutional right to trial by jury where applicable.
8.5 Injunctive Relief
Nothing herein limits the Designated Court’s authority to issue temporary, preliminary, or permanent injunctive relief to enforce health care directives.
9. GENERAL PROVISIONS
9.1 Amendments
This Instrument may be amended only by a writing executed with the same formalities as this Instrument.
9.2 Waiver
No waiver of any provision is effective unless in writing and signed by the waiving party. A waiver on one occasion is not a waiver on any subsequent occasion.
9.3 Assignment
The rights and duties under this Instrument are personal to the individuals named and may not be assigned.
9.4 Successors & Assigns
This Instrument binds and benefits Principal’s heirs, executors, administrators, and legal representatives.
9.5 Severability
If any provision is held unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to fulfill its intended purpose to the maximum extent permitted by law.
9.6 Integration
This Instrument constitutes the entire understanding among the parties with respect to the subject matter hereof and supersedes all prior directives.
9.7 Counterparts & Electronic Signatures
This Instrument may be executed in multiple counterparts, each of which is deemed an original. Signatures transmitted electronically or by facsimile are deemed original signatures.
10. EXECUTION BLOCK
10.1 Principal
[PRINTED NAME OF PRINCIPAL]
Date: _______
10.2 Acknowledgment by Agent
I, [NAME OF AGENT], have read this Instrument and accept the appointment as Agent. I understand my fiduciary duties and agree to act in good faith and in accordance with the Principal’s wishes and Indiana law.
[PRINTED NAME OF AGENT]
Date: _______
10.3 Acknowledgment by Successor Agent(s)
[Duplicate as necessary for each Successor Agent.]
[PRINTED NAME OF SUCCESSOR AGENT #1]
Date: _______
10.4 Witness Attestation
We declare that the Principal voluntarily signed this Instrument in our presence, appears to be of sound mind, and is at least eighteen (18) years of age. We are not (a) the Agent or Successor Agent, (b) related to the Principal by blood, marriage, or adoption, nor (c) entitled to any portion of the Principal’s estate.
Witness #1: ___ Date: _
Print Name: ______
Witness #2: ___ Date: _
Print Name: ______
10.5 Notary Public
State of Indiana )
County of [__] ) ss:
Subscribed and sworn before me on this _ day of __, 20___, by [NAME OF PRINCIPAL].
Notary Public, State of Indiana
My Commission Expires: ____
Notary Seal:
[// GUIDANCE: File the fully executed original in a readily accessible location. Provide copies to Agent, Successor Agent(s), primary physician, and applicable health care facilities. Consider uploading a digital copy to the Indiana Advance Directive Registry if available.]