- Jurisdiction
- Indiana
- Purpose
- Medical & health care
- Source / form version
- Version 3, April 12, 2023
- Resource format
- Signing
- This two-page version uses two adult witnesses; at least one must not be the declarant’s spouse or relative. Follow its witness statements and the Indiana advance-directive rules.
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Open PDF in a new tab (opens in a new tab)Sources checked: 2026-11-13. General information, not individual legal advice.
A short representative appointment
Indiana Disability Rights publishes this two-page appointment with a separate planning toolkit. It names a primary representative and one backup. The representative must follow the person’s wishes and values, including views about dignity and quality of life; when wishes are unknown, the document directs decisions in the person’s best interests.
Complete both pages
The second page contains the signature, date and witness declarations. It also expressly revokes earlier health care powers and representative appointments. Read that clause against existing documents before replacing them. The telephone-witnessing initial is for that particular execution method; it is not a routine box everyone must select.
Add a conversation about treatment
This appointment emphasizes who will speak for you. Indiana Disability Rights also provides a planning sheet to work through treatment values and practical preferences. Share those choices with the representative and providers. Indiana’s health department says there is no mandatory state advance-directive form, but the requirements of IC 16-36-7 still apply. Keep the backup’s telephone number current. A complete appointment is easier to use when the primary representative and alternate both know that they were named.
Common questions
Is a planning sheet the signed appointment?
No. The toolkit separates preparation from the representative form. Complete and sign the appointment using its required procedure.
Related forms and guides
Sources and verification
- Indiana Disability Rights: source and instructions (opens in a new tab)
- Published form (opens in a new tab)
- Indiana Department of Health advance-directive guidance (opens in a new tab)
- Indiana Disability Rights planning sheet (opens in a new tab)
Two-page PDF downloaded, text inspected; no AcroForm fields detected despite the toolkit page’s general computer-fill description. Labelled printable, not interactive-fillable.
The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.