Statutory Advance Directive
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8Statutory Advance Directive
For Indiana Residents
____________________________
_____________________
Print Full Name
Date of Birth
Your right (when age 18 or older): To Document Your Personal Wishes,
and to have these wishes followed ~~
The Indiana state legislature designed a Living Will for use by the public, and provided
statutes guiding the construction of a Power of Attorney for Health Care. As these documents
were designed/structured by your state government, each is in full compliance with all applicable
laws, statutes, and ordinances.
There is an introduction that summarizes the scope and purpose of the document, as well
as providing directions for its completion. Read it carefully to ensure that your Advance
Directive is fully and properly filled out.
By completing these documents, you can have the peace of mind that your wishes can be
known and followed. It is also a meaningful gift to those you love, who will have to make fewer
difficult choices for you without an understanding of what you would want done.
Understanding Your Directive:
To make the best choices for your medical care, your physician needs to know your
wishes. In fact, the law requires doctors to seek your permission before giving you any
treatment. However, if you are ever unable to speak due to severe illness or injury, this may not
be possible. Completing this Directive will help your family and physicians know who should
speak for you, and understand what you want, if you cannot speak for yourself.
You can revoke (cancel) this directive at any time by: 1) writing “revoked” across the
front of the directive, followed by your signature and date, and the signature of at least one
witness age 18 years or older ; or 2) by completing a Notice of Revocation; or 3) by telling an
adult witness that you want it revoked (who must then sign and date a statement, which becomes
effective only when given to your doctor or health care provider); or 4) by simply completing a
new directive in which you state that any prior directive is no longer valid.
If you are unable to write, you may tell your directive witnesses what you want to have
excluded, limited, or added to this directive. They must then sign, date, witness and/or notarize
the statement of the limitations and exclusions as you have described them.
Remember, unless you direct otherwise, this directive will only be used to guide your
family and doctors if you are unable to make and communicate medical decisions yourself.
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