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
Facility or Provider (optional)
Healthcare Facility or Provider
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
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my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care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
(number and street, city, state, and ZIP code)
Telephone Number of Representative
Signature of Patient / Appointor or
Designee (must be signed in the
appointor’s presence)
Printed Name of Patient / Appointor or
Date of Appointment (mm/dd/yyyy)
Signature of Witness Printed Name of Witness
Date (mm/dd/yyyy)
Reset Form
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
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
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