State Form 56184 - Indiana Health Care Representative Appointment (Page 2 of 2) in pdf

INSTRUCTIONS FOR STATE FORM 56184, INDIANA HEALTH CARE REPRESENTATIVE APPOINTMENT

1. There are numerous types of advance directives. The Indiana State Department of Health encourages

individuals to consult with their attorney, health planner, and health care providers in completing any

advance directive.

2. This state form is not required for an appointment of a health care representative. An individual may use

a form designed by their attorney or other entity to specifically meet the individual’s needs. To be valid,

any form must comply with statutory requirements.

3. An individual is not required to complete a health care representative appointment form. An individual

may always chose to not appoint a health care representative. If there is no appointed representative,

state medical consent laws would determine who may consent to your healthcare.

4. The medical record number and health care facility or provider is not required for the appointment to be

effective. It may be included as a means of assisting the health care provider in identifying the correct

patient and locating the appointment in the correct medical record.

5. The patient / appointor may specify in the appointment appropriate terms and conditions, including an

authorization to the representative to delegate the authority to consent to another.

6. The authority granted becomes effective according to the terms of the appointment.

7. The appointment does not commence until the appointor becomes incapable of consenting. The

authority granted in the appointment is not effective if the patient / appointor regains the capacity to

consent.

8. Unless the appointment provides otherwise, a representative appointed under this section who is

reasonably available and willing to act has priority to act in all matters of health care for the patient /

appointor, except when the patient / appointor is capable of consenting.

9. The appointment of a health care representative must be witnessed by an adult other than the health

care representative.

10. In making all decisions regarding the patient’s / appointor’s health care, the health care representative

shall act:

a. In the best interest of the patient / appointor consistent with the purpose expressed in the

appointment.

b. In good faith.

11. A health care representative who resigns or is unwilling to comply with the written appointment may not

exercise further power under the appointment and shall so inform the following:

a. The patient / appointor.

b. The patient’s / appointor’s legal representative if one is known.

c. The health care provider if the representative knows there is one.

12. An individual who is capable of consenting to health care may revoke:

a. The appointment at any time by notifying the representative orally or in writing; or

b. The authority granted to the representative by notifying the health care provider orally or in

writing.

State Form 56184 - Indiana Health Care Representative Appointment Page 2