» » Indiana Living Will Declaration (Form 55316)

Indiana Living Will Declaration (Form 55316)

Create a high quality document online now!

The Indiana Living Will Declaration, also known as “Form 55316”, is a legal document that protects the rights of a Declarant/Principal and their decisions for their health care in the event they are met with an end of life scenario and are unable to express their own decisions when they become incapacitated. This document will assist in the guidance of what the declarant would like their medical team to do when there are no other options for life-sustaining treatment. This document may be revoked at any time as long as the Declarant/Principal is of sound mind to perform revocation. If at any point the Declarant/Principal does not feel that they understand the document and its contents, that may wish to consult with an attorney prior to completion.

Laws – IC 16-36-4-10

Signing Requirements – Two (2) Witnesses

Life Prolonging Procedures Will Declaration (Form 55315) – To be used in conjunction with a living will declaration to make it known to any hospital that the patient requests any means necessary to prolong their life.

Health Care Representative Appointment (Form 56184) – For the establishment of a health care agent to make decisions on a Principal’s behalf if they are not able to do them on their own.

How to Write

Download: Adobe PDF, MS Word (.doc), OpenDocument

Step 1 – Declaration – Download the form and begin by entering:

  • Date of the declaration in dd/mm/yyyy format

Step 2 – Declarant/Principal Review of Statement – The Declarant must carefully review the statements provided on the form. If the Declarant understands and is in agreement, provide a response to the statement, by initialing the appropriate lines preceding each statement (if any)

Step 3 – Declarant/Principal Signature – The Declarant must read the final paragraph of this section. If in agreement, the Declarant will enter the following:

  • The Declarant’s Signature
  • Enter the Declarant’s City, County and State of Residence

Step 4 – Witness Signatures – This document will require the review and signatures of two (2) witnesses. The witnesses must carefully read the information in this section. If in agreement, the witnesses must enter the following into the form:

Witness 1 –

  • Witness’s Signature
  • Date the signature in mm/dd/yyyy format

Witness 2 –

  • Witness’s Signature
  • Date the signature in mm/dd/yyyy format