Medical Power of Attorney Indiana (Form 56184) – PDF

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The Indiana medical power of attorney, also known as “Form 56184”, is used to appoint a health care representative to make medical decisions for the principal in the event of their incapacitation. It is important that individuals choose someone who can be available locally to meet with the principal’s health providers and share their basic values regarding healthcare. Therefore, many individuals choose their spouse to be their representative.

This document’s official name is the “Health Care Representative Appointment“. This form, when combined with the Living Will Declaration (Form 55316), is known as the “Indiana Advance Directive”.

LawsIC 16-36 (Health Care Consent)

Signing Requirements (§ 16-36-1-7(b)(3)) – To be legally validated it must be signed by the principal and at least one (1) adult witness.

Related Medical Forms

Life Prolonging Procedures Will Declaration (Form 55315) – To make it known to hospitals and medical staff that the patient intends on extending their life as long as possible. (IC 16-36-4-11)

Living Will Declaration (Form 55316) – For the creation of a written instrument that gives medical staff your desires/wishes in the event of an incapacitated state with no cure. (IC 16-36-4-10)

Indiana Medical Power of Attorney Form

Download: Adobe PDF, MS Word (.docx)

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