Indiana Advance Directive

Information you will need

• Declaration Date
• Principal City, County, and State Residence
• First Witness Signature Date
• Second Witness Signature Date
• Principal Last Name
• Principal First Name
• Principal Name
• Principal Middle Initial
• Principal Date of Birth
• Medical Record Number
• Healthcare Facility or Provider Name
• Additional Terms and Conditions
• Representative Name
• Representative Address
• Representative Telephone Number
• Date of Appointment
• Witness Name
• Witness Signature Date
• Artificial Nutrition and Hydration
• No Artificial Nutrition and Hydration
• No Decision
• Declaration Month and Year

Completed by the declarant and the provider.

The form includes 3 signature lines, a witness section.