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Form #1130Appointment of Health Care Representative - Indiana
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Appointment of Health Care Representative, Indiana
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APPOINTMENT OF HEALTH
CARE REPRESENTATIVE
I appoint _______________________, of
_______________________________Â , as my Health
Care
Representative to act for me in matters of health care in accordance with IC
16-8-12. Among the powers granted to my Health Care Representative, it is my
intention to include the power to select, engage and discharge health care
providers and facilities and the power to withhold or withdraw consent to
health care as well as the power to grant consent. In the event of the inability
of____________________________ to serve in such capacity, for any reason, then
I appoint, in successive order, the following individuals to serve as my Health
Care Representative:
                                                               _________________________________________
                                                               _________________________________________
This
appointment is subject to the following terms and conditions:
I
have executed a Living Will and request that my Health Care Representative
honor my
wishes as expressed therein.
My
Representative is authorized to delegate all or part of this authority to any
eligible individual who has not been disqualified as provided in IC 16-8-12.
This
appointment of my Health Care Representative is not to be considered a
contradiction of a Living Will I may execute, whether simultaneously,
previously, or hereafter. My Living Will shall be considered as expressing my
intention, but my Health Care Representative’s action is consenting to,
withholding of or withdrawing consent to life-prolonging procedures shall take
precedence.
IN
WITNESS WHEREOF, I have hereunto set my hand and seal on the ______ day of _______________
                                                                                                                                                                                                                                             ______________________________________
WITNESSES
I certify that I,
____________________________, am of legal age, that I reside at: ____________________________
and that I have witnessed the foregoing appointment.
                                                                                                                                               __________________________________
WITNESS
I
certify that I, ____________________________, am of legal age, that I reside
at: ____________________________ and that I have witnessed the foregoing
appointment.
                                                                                                                                               __________________________________
                                                                                                                                               WITNESS
Attorney Advertising
Dugan & Repay LLP
is only advertising in states where they are admitted to practice
|
Contributed by
Dugan & Repay LLP |
 |
|
Name of Firm |
Dugan & Repay LLP |
|
Profession |
Lawyer |
|
Number of lawyers in firm |
2 |
|
Branch of Law |
Personal Injury, Workers Compensation, Estate Planning, Family, Employment & Labor, |
|
Location |
Schererville,
Indiana,
United States |
|
Principal Office Address |
Dugan & Repay LLP
7656 Harvest Drive
Schererville, IN 46375 |
|
Practicing law since |
1/1/1997 |
|
Total Forms Contributed |
3 |
|
Phone |
2198649922 |
|
Website |
http://www.dr-legal.com |
|
Email |
|
|
Full service law firm |
State Advertising Disclaimer:
Dugan & Repay, LLP is only advertising in states where they are admitted to practice.
Dugan & Repay, LLP is only advertising in states where they are admitted to practice.
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See All
Dugan & Repay LLP's Forms |
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regading how we deal with your email. We pledge that we will:
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legal council before engaging in any action based upon content contained on this
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or any other commercial use is prohibited. This includes reposting forms from this
site to another site offering free legal or other document forms for download.
Please note that the donator may have included different usage terms regarding this
form, and you agree to abide by these terms. It is highly recommended that you have
a licensed attorney review any legal documents for which you are searching in order
to make sure that your needs are being properly and completely satisfied.
Your use of this site constitutes your acceptance of our terms of use and your agreement
to hold this site, its officers, employees and any contributors to this site harmless
for any damage you might incur from your use of any submissions contained on this
site. If you do not agree to the above terms, please do not proceed.
These forms are provided to assist business owners and others in understanding important
points to consider in different transactions. They are offered with the understanding
that no legal advice, accounting, or other professional service is being offered
by these documents or on this website. Laws vary in the different states. Agreements
acceptable in one state may not be enforced the same way under the laws of another
state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com
is not engaged in recommending or referring members on the site or making claims
about the competence, character or qualifications of its participating members.
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Keywords: Indiana, Health Care Representative, Estate Planning
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