Get In State Form 56184 2016-2025

Completing the Indiana Health Care Representative Appointment (State Form 56184) online is a crucial step in ensuring your healthcare wishes are honored. This guide provides clear instructions for users to navigate each section of the form effectively.

Follow the steps to fill out your form with ease.

1. Click ‘Get Form’ button to acquire the form and open it in the editor.
2. Start by filling out the patient/appointor information. Enter the patient’s last name, first name, middle initial, and birthday in the specified format (mm/dd/yyyy).
3. If applicable, provide the medical record number and the healthcare facility or provider's name. This information can help identify the patient but is not required for the appointment to be effective.
4. In the 'Appointment of Health Care Representative' section, designate the person you wish to appoint as your health care representative. Include their name, address, and telephone number.
5. Sign the form as the patient/appointor or designee in the presence of a witness. Make sure to print your name below your signature.
6. The witness must also sign the form, providing their printed name and the date of signing (mm/dd/yyyy). Remember, the witness should be an adult who is not the appointed health care representative.
7. Finally, review all sections to ensure accuracy. Once you are satisfied, you can save your changes, download, print, or share the completed form.

Complete your health care representative appointment form online today.