Home Join Now Learn More Sign in
Home | Admin | Sign Out 
Find a Form 

Access thousands of free legal and business forms contributed by leading lawyers and other professionals

Search by key words (e.g., "Sales Contract")
Advanced search

 
Promote Your Business  
  • Contribute a legal or business form and network with thousands of potential clients, businesses, and professionals

    Upload a Form Add Your Executive Profile
Promote Your Business 
  • Contribute a legal or business form and network with thousands of potential clients, businesses, and professionals

    Upload a Form Add Your Executive Profile
Promote your business  
  • Contribute a legal or business form and network with thousands of potential clients, businesses, and professionals

    Upload a Form Add Your Executive Profile
Add your free profile  
  • Contribute a legal or business form and network with thousands of potential clients, businesses, and professionals

    Upload a Form Add Your Executive Profile
 
Connect

Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, 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.
Close

Thank you for using
Yourfreelegalforms.com


Your online source for 100% free legal and business forms.
Have a form to contribute?
Contribute a legal or business form, checklist or article and have your profile displayed on the same page as the form for free, powerfull, targeted marketing to those searching for legal forms and advice.

Advertise your business to thousands for free – Contribute a form
Form #1130

Appointment of Health Care Representative - Indiana

Average user rating:  
Not Yet Rated
Rate it

Appointment of Health Care Representative, Indiana

Need this form customized? Download This Form Printer Friendly Version

APPOINTMENT OF HEALTH CARE REPRESENTATIVE

 

I appoint _______________________, of _______________________________  , 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 symbol)   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.

See All Dugan & Repay LLP's Forms
 

Related Forms

Appointment of Guardian
Living Will Declaration - Indiana
BOARD OF DIRECTORS' RESOLUTION FOR APPOINTMENT OF ATTORNEYS
PURCHASER REPRESENTATIVE QUESTIONNAIRE
Designation of Health Care Surrogate

Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, 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.
Close

Thank you for using
Yourfreelegalforms.com


Your online source for 100% free legal and business forms.
Have a form to contribute?
Contribute a legal or business form, checklist or article and have your profile displayed on the same page as the form for free, powerfull, targeted marketing to those searching for legal forms and advice.



Was this form helpful? Yes No
Need a different form? Yes No


Need a different form? Need a custom form or service?

Contact this contributor  or post a request to our community.

If you found this form useful, you might consider using Dugan & Repay LLP's professional services. Dugan & Repay LLP can be reached at 2198649922, emailed at , or visit his website at http://www.dr-legal.com.



Comments




Keywords: Indiana, Health Care Representative, Estate Planning

close