Download in English. Other versions available on the Advanced Directive Resources page.
A Health Care Representative is a person chosen by you to make health care decisions, including end of life decisions, if you are unable to make your own decisions.
My legal name is (also known as "Declarant"): _________________________________________
My Health Care Representative can make decisions for me if I cannot make and share my own health care decisions. My Health Care Representative must follow my wishes and values. My values include my ideas about dignity and quality of life. If my Health Care Representative does not know my wishes, my Health Care Representative must act in good faith and make decisions in my best interests. These decisions include:
- agreeing to medical treatment;
- refusing medical treatment;
- stopping medical treatment; and
- arranging comfort care.
I want the following person to by my Health Care Representative (HCR):
HCR Name: _________________________________________
HCR Phone Number: __________________________________
If my primary HCR named above is not able or available to act for me, I want the following person to be my backup HCR:
Backup HCR Name: _____________________________________________________
Backup HCR Phone Number: ______________________________________________
By signing this form, I hereby revoke any and all previous health care power of attorney and health care representative form(s).
Printed Name (Declarant) _____________________________________________
Signature (Declarant or Representative) __________________________________ Date __________________
Print name of adult (if any) who signs for Declarant (if Declarant is physically unable to sign) _______________________________________________________
I have initialed the following space if I signed this Advanced Directive after talking with and listening to two (2) witnesses by telephone only __________________
Signature of Two Adult Witnesses
Each of the undersigned Witnesses confirm that they have received satisfactory proof of the identity of the Declarant, is satisfied that the Declarant is of sound mind, and has the capacity to sign the above Advanced Directive. At least one of the undersigned Witnesses is not a spouse or other relative of the Declarant.
Signature of Adult Witness 1 ____________________________________________________________
Printed Name of Adult Witness 1 _________________________________________________________
Date _______________________________
Signature of Adult Witness 2 ____________________________________________________________
Printed Name of Adult Witness 2 _________________________________________________________
Date _______________________________
This Advanced Directive project was funded by the Indianapolis Bar Foundation.
Version 3: Last updated 23.4.12