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Indiana Health Care Representative Appointment (Form 56184)

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Indiana Health Care Representative Appointment, also known as ‘Form 56184’, grants power to someone else to make medical decisions on your behalf if you are incapable of doing so. In this paperwork, you will be referred to as the “principal” and the person you elect will be referred to as your “health care representative”. In addition to delivering this authority, this form allows you to offer solid documentation of the instructions of your health care instructions and preferences as well as provisions for end of life preferences. Generally, putting such directives in writing will remove most ambiguities regarding your health care choices provided a complete report of these wishes is supplied.  This is an important form to have executed before you have surgery or some other scheduled or unscheduled medical procedure where you will be under anesthesia or otherwise incapacitated.

Laws§ 16-36‌-1


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How to Write

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

Step 1 – Acquire The Indiana Appointment Form To Name A Health Care Representative

The template featured in the preview image on this page can be obtained with any of the buttons bearing the file type icon and label of the version they access. This Indiana appointment is available as a PDF, Word, or ODT file.

 

Step 2 – Identify Yourself As The Principal Or Appointor

This paperwork will be composed of several distinct areas. The first of which is a brief table titled “Patient/Appointor Information.” As the person who wishes to designate a Health Care Representative with (your) principal medical decision-making powers, you must document your last name, first name, and middle initial on the first row. Use the boxes designated as “Patient Last Name,” “Patient First Name,” and “Patient Middle Name” to satisfy this request.  Anyone reviewing this paperwork will wish to see some additional items further defining your identity. Traditionally, this item is your date of birth. Thus, locate the first box on the second row and record it in under the label “Patient Birthday (mm/dd/yyyy).” Note the two-digit month, two-digit calendar day, and the four-digit year is the format requested. 

 

Step 3 – Report Some Optional Information If It Is Available

If you have a “Medical Record Number Of Healthcare” with a specific Medical Facility or Provider where you are likely to be treated for injuries or illnesses then you can submit it to the second cell of the second row to further identify yourself to any Medical Personnel who must review this document in the future. This is optional so you may leave this area unattended.  As an added measure, if you have supplied a medical record number, you should also name the “Healthcare Facility Or Provider” that originated that record number in the last box of this row. This is also optional, however, if you provided a record number it is strongly recommended you supply this content.   

 

Step 4 – Review The Appointment

The section titled “Appointment Of Health Care Representative” should be closely reviewed. This section contains the declaration statement that shall be applied as the intent of the Indiana Resident identified in the “Patient/Appointer Information” above. Once you sign your name, you will be publicly testifying that all the information in this section is true and a valid representation of your intentions.  You will have an opportunity to directly list your health care preferences and directives however, before doing so, you should take a moment to review the second page of this document. The “Instructions For State Form 56184…” page will deliver valuable information explaining what the Patient and the Representative can or cannot do, when the appointment being developed here is effective (by default), and how this form in general will interact with the law and medical institutions.  

 

Step 5 – Directly Grant Or Limit Representative Powers Available To Your Agent

Now that you have recorded yourself as the Principal or Patient in this document and reviewed the information presented, you can set your health care instructions or directives down on paper. For this task, you will need to return to the section titled “Appointment Of Health Care Representative.” Locate the statement reading “I Specify The Following Terms And Conditions.” The text box underneath this statement is reserved for your use. Here, you may address as many scenarios as you wish and provide the answers to medical decisions you may anticipate. You may also address when the Health Care Agent has the power to make such decisions. For instance, this document will automatically become effective upon your incapacitation and terminate when you are able to communicate once again. You may wish to set up a time limit for when your Agent will have power, or you may wish to limit his or her decision-making powers in certain scenarios. You may be as specific as you like or merely give a summary of your feelings on certain matters since this document will assume that your Health Care Representative and you have a strong understanding of your medical preferences. 

 

Step 6 – Appoint Your Indiana Health Care Representative

The Health Care Representative you plan to empower with the same medical decision-making powers you possess over your health care and treatment must be identified in this appointment. A concise table directly below your directives will aid you in satisfying this requirement. Begin by recording the full name of your Indiana Health Care Representative in the first box of this table (labeled “Name Of Representative Appointed”).  The second cell of this table expects the Health Care Representative’s full address. This should be his or her legal residence in Indiana and the address of the physical location where the Health Care Representative can be visited if necessary.  The third box of this row is also concerned with the ability to contact the Health Care Representative when necessary. Present his or her phone number in the “Telephone Number of Health Care Representative.” You may provide as many phone numbers as is appropriate (i.e. cell phone, work number, home landline). The phone number reported here may be used to contact the Health Care Representative during an emergency event, so make sure this is a well-maintained method of communication for the Health Care Agent. Furthermore, if providing more than one telephone number, list them in order of reliability. For instance, if your Health Care Representative is a driver and you are documenting his or her home phone number and a cell phone number, it is recommended you place the cell phone number first especially if it is always on his or her person.   

 

Step 5 – Signify Your Intent With A Witnessed Execution Of This Form

The second row of this table requires that you acknowledge and set the terms it contains and the directives you provided in motion with a signature before two Witnesses. First, locate the “Signature Of Patient/Appointor or Designee” box then sign your name in its boundaries. If you are an Attorney-in-Fact or Court-Appointed Guardian signing this document on another’s behalf this act must be done in the presence of the Appointor as well as a Witness.  You must print your name in the “Printed Name Of Patient/Appointor Or Designee” box for clarification.  Finally, produce the current calendar date in the “Date Of Appointment (mm/dd/yyyy)” box.   The individual who has witnessed your act of signing (or the act of a Designee signing before the Principal and the Witness) must verify his or her presence at the time thus, the Witness must provide his or her signature in the “Signature Of Witness” box. Notice, this is located in the next row directly below the signature you provided.   The Witness should further define his or her identity by printing his or her name in the “Printed Name Of Witness” box.   Immediately after signing and printing his or her name the Witness must document the current calendar day in the “Date (mm/dd/yyyy)”


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