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Or 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 (optional) 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, includin.
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Givers FAQ
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A healthcare representative, like a healthcare agent is a person one may appoint to make medical decisions for them should a time come when they cannot make medical decisions for themselves. This document can be very advantageous at the right time.
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A health care representative is someone you choose to make medical decisions for you if you cannot. What form should I use? Health care representative forms are available in English and Spanish on the Indiana State Department of Health website.
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An Indiana medical power of attorney, also known as “Health Care Representative Appointment,” grants power to one person (a “health care representative”) to make medical decisions on another person's (a “principal”) behalf if the latter is incapable of doing so for themselves.
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What is an Indiana Medical Power of Attorney? An Indiana Medical Power of Attorney is a legal document that grants a trusted person the authority to make healthcare decisions on your behalf, such as accepting or refusing certain medical treatments and procedures, when you cannot do so.
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Indiana Code § 16-36 allows any member of your immediate family (meaning your spouse, parent, adult child, brother, or sister) or a person appointed by a court to make the choice for you.
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Section 16-36-7-1 - General provisions (a) A death as a result of the withholding or withdrawal of life prolonging procedures in ance with: (1) a declarant's advance directive; or (2) any provision of this chapter; does not constitute a suicide.
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An Indiana medical power of attorney, also known as “Form 56184”, is used to appoint a healthcare representative to make medical decisions for the principal in the event of their incapacitation.
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