Fillable Statutory Advance Directive (Page 7 of 8) in pdf

A. I authorize my health care agent to make decisions in my best interest concerning

withdrawal or withholding of health care, including but not limited to the

provision of artificial nutrition and hydration. If at any time, based on my

previously expressed preferences and the diagnosis and prognosis, my health care

representative is satisfied that certain health care is not or would not be beneficial,

or that such health care is or would be excessively burdensome, then my health

care representative may express my will that such health care be withheld or

withdrawn and may consent on my behalf that any or all health care be

discontinued or not instituted, even if death may result. My health care

representative must try to discuss this decision with me. However, if I am unable

to communicate, my health care representative may make such a decision for me,

after consultation with my physician or physicians and other relevant care givers.

To the extent appropriate, my health care representative may also discuss this

decision with my family and others, to the extent they are available.

B. Consent, refuse consent, renew or withdraw consent to any treatment, tests,

medications, care, services, surgery or therapies used to diagnose or treat any

physical or mental condition.

C. To employ or contract with medical and personal care providers necessary for my

health care.

D. To admit and discharge me from any hospital or other health care facility.

E. To request, review, receive, and disclose any medical information, verbal or written,

needed to follow and manage my physical or mental health treatment and general

care, and to authorize the release of my medical records or any other

documentation needed to continue my treatment in or outside of any health care

setting or service. This release authority applies to any information governed by

the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 42

U.S.C. 1320d and 45 CFR 160 through 164.

F. To make anatomical gifts on my behalf.

G. To authorize autopsy, if desired by my physicians or by my agent.

Additional Agent Instructions:

27. I also wish to add the following instructions to my agent: __________________________

_____________________________________________________________________

STATEMENT AND SIGNATURE OF PRINCIPAL/GRANTOR:

28.

This document is governed by Indiana law, although I request that it be honored in any

state in which I may be found.

By signing below, I indicate that I am fully aware of the contents of this document, and

Statutory Advance Directive Page 7