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Health Care Directive

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DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I, _________________________, of ____________________________, ______________________________, Indiana __________, being of sound mind, voluntarily create this Durable Power of Attorney for Health Care.

PRIOR DESIGNATIONS
I revoke any prior Durable Power of Attorney for Health Care.

APPOINTMENT OF HEALTH CARE ATTORNEY-IN-FACT
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my attorney-in-fact for health care decisions:

Name: _______________________
Address: _______________________, _______________________, Indiana, __________
Telephone: ______________________________
Relationship: _______________________

ATTORNEY-IN-FACT'S AUTHORITY
My attorney-in-fact is authorized to act for me in all matters relating to my health care. My attorney-in-fact's powers include, but are not limited to:

  • Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my attorney-in-fact by me;
  • Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my attorney-in-fact by me;
  • Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and the American Recovery and Reinvestment Act of 2009 ("ARRA");
  • Full power to sign any releases in order to obtain this information;
  • Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My attorney-in-fact does not have authority to act for me for any other purpose unrelated to my health care. All of my attorney-in-fact's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

WHEN ATTORNEY-IN-FACT'S AUTHORITY BECOMES EFFECTIVE
The designation of my attorney-in-fact will become effective as soon as this document is signed and will remain in effect until my death, or until I revoke it. This designation will not be affected by my subsequent disability or incompetence.

ATTORNEY-IN-FACT'S OBLIGATIONS
My attorney-in-fact will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my attorney-in-fact. To the extent my wishes are unknown, my attorney-in-fact will make health care decisions for me in accordance with what my attorney-in-fact determines to be in my best interest. In determining my best interest, my attorney-in-fact will consider my personal values to the extent known to my attorney-in-fact.

The remainder of this document will be available when you have purchased a license.


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