YOUR INSTRUCTIONS INDIANA ADVANCE DIRECTIVE PAGE 1 OF 8 – PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE AND POWER OF ATTORNEY PRINT YOUR NAME AND ADDRESS I, (name) of PRINT THE NAME, (address) ADDRESS AND TELEPHONE hereby appoint NUMBERS OF (name of health-care representative) HEALTH-CARE (address) (home telephone number) (work telephone number) representative and attorney-in-fact, if I have had this document — notarized on page 7 (“health-care representative”) to make health-care — decisions on my behalf whenever I am incapable of making my own health-care decisions. THE NAME, ADDRESS AND In the event the person I appoint above is unable, unwilling or unavailable TELEPHONE to act as my health-care representative, I hereby appoint: NUMBERS OF YOUR SUCCESSOR HEALTH-CARE REPRESENTATIVE (name of successor health-care representative) as my of care (address) (home telephone number) (work telephone number) as my successor health-care representative.
INSTRUCTIONS PRINT YOUR NAME AND ADDRESS PRINT THE NAME, ADDRESS AND TELEPHONE NUMBERS OF YOUR INDIANA ADVANCE DIRECTIVE – PAGE 1 OF 8 PART ONE: APPOINTMENT OF HEALTH-CARE REPRESENTATIVE AND POWER OF ATTORNEY I, (name) of (address) hereby appoint (name of health-care representative) HEALTH-CARE (address) (home telephone number) (work telephone number) THE NAME, ADDRESS AND TELEPHONE NUMBERS OF YOUR SUCCESSOR HEALTH-CARE REPRESENTATIVE as my representative — and attorney-in-fact, if I have had this document notarized on page 7 — (“health-care representative”) to make health-care decisions on my behalf whenever I am incapable of making my own health-care decisions. In the event the person I appoint above is unable, unwilling or unavailable to act as my health-care representative, I hereby appoint: (name of successor health-care representative) of (address) (home telephone number) (work telephone number) as my successor health-care representative. care