State Form 56184 - Indiana Health Care Representative Appointment printable pdf download

INDIANA HEALTH CARE REPRESENTATIVE APPOINTMENT

State Form 56184 (11-16)

Indiana State Department of Health – IC 16-36-1; IC 16-36-6

INSTRUCTIONS: See instructions on back.

Patient / Appointor Information

Patient Last Name

Patient First Name

Patient Middle Initial

Patient Birthday (mm/dd/yyyy)

Medical Record Number of Healthcare

Healthcare Facility or Provider

Facility or Provider (optional)

(optional)

Appointment of Health Care Representative

I, being at least eighteen (18) years of age, of sound mind, and capable of consenting to my health care, hereby

appoint the person(s) named below as my lawful health care representative in all matters affecting my health

care, including but not limited to providing consent or refusing to provide consent to medical care, surgery,

and/or placement in health care facilities, including extended care facilities, unless otherwise provided in this

appointment. This appointment shall become effective at such time and from time to time as my attending

physician determines that I am incapable of consenting to my health care. I understand that if I have previously

named a health care representative the designation below supersedes (replaces) any prior named Health Care

Representative(s).

I authorize my health care representative to make decisions in my best interest concerning withdrawal or

withholding of health care. 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my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care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 health 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.

I specify the following terms and conditions (if any):

Name of Representative Appointed

Address of Representative

Telephone Number of Representative

(number and street, city, state, and ZIP code)

Signature of Patient / Appointor or

Printed Name of Patient / Appointor or

Date of Appointment (mm/dd/yyyy)

Designee (must be signed in the

Designee

appointor’s presence)

Signature of Witness

Printed Name of Witness

Date (mm/dd/yyyy)

State Form 56184 - Indiana Health Care Representative Appointment

Related Articles

Related forms

Related Categories