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11109 Parkview Plaza Drive
Fort Wayne, IN 46845
11050 Parkview Circle
11108 Parkview Circle
Parkview Regional Medical Center Campus
11130 Parkview Circle Drive, Entrance 7
11115 Parkview Plaza Drive
2200 Randallia Drive
Fort Wayne, IN 46805
1720 Beacon Street
1316 E. 7th Street
Auburn, IN 46706
2001 Stults Road
Huntington, IN 46750
207 North Townline Road
LaGrange, IN 46761
401 Sawyer Road
Kendallville, IN 46755
10 John Kissinger Drive
Wabash, IN 46992
1260 East State Road 205
Columbia City, IN 46725
1355 Mariners Drive
Warsaw, IN 46582
10622 Parkview Plaza Drive
Below you will find links to a variety of forms you may need during your time with Parkview.
You may appoint a healthcare representative to make medical decisions in the event you become incapacitated. You may specify instructions to be followed by your healthcare representative, who must act in good faith and in your best interest, consistent with the terms of the appointment. In order to be best prepared to honor your best interests, the person who is appointed as your healthcare representative should be made aware of your philosophies, ideologies and faith traditions.
To appoint a valid healthcare representative, you must complete and sign the Appointment of a Healthcare Representative form, and it must be witnessed by an adult other than the appointed representative. In the event that you become incapacitated, the healthcare representative is the sole determiner of your medical choices.
The appointment may be revoked at any time by notifying the representative verbally or in writing. The authority granted by you to the representative through an appointment may be revoked by notifying the healthcare provider verbally or in writing.
Appointment of a healthcare representative form
Appointment of a healthcare representative form (Spanish)
When your child is injured or becomes ill and you can’t be there, we’ll provide the necessary medical attention. This form enables healthcare professionals to treat your child for minor emergencies when, and only when, you cannot be notified.
By filling out the form, you'll be able to provide not only your permission for medical treatment, but also important health information needed for the care of your child. You may want to keep one copy for yourself and give another copy to the person who will be responsible for your child when you cannot be present. Be sure to specify that person’s name on the form.
A life-prolonging declaration mandates the implementation of all life-prolonging procedures necessary to extend life. You should use the declaration if you want extraordinary or heroic measures used to prolong your life.
The declaration orders the use of all medical procedures to prolong life, including appropriate nutrition and hydration, medication to ease pain and comfort care. Declarations must be voluntary, in writing, signed by you, the patient making the declaration, dated and witnessed by at least two individuals.
These witnesses may not be:
As in the case of a living will, a life-prolonging procedures declaration does not become effective until certain conditions are met by the patient:
As the patient, you may revoke a life-prolonging procedures declaration at any time by a signed and dated revocation, physical cancellation such as destroying the declaration, or by telling someone that it is no longer in effect. If the life-prolonging procedures declaration is revoked, the physician must be informed.
Life-prolonging procedures form
A living will is a document that provides instructions for your care in the event of a terminal condition. This condition may be the result of an incurable injury, disease or illness, and death is imminent without life-prolonging procedures.
Competent adults have the right to control the decisions related to their medical care, including life-prolonging procedures. The living will serves as the final expression of your right to refuse treatment and accept the consequences of the refusal.
The living will directs withholding or withdrawing of procedures that artificially sustain vital functions and prolong the dying process. It is your request for permission to die naturally with only the provision of appropriate pain easing medication and comfort care. In addition, when making a living will, you have a choice about whether you want to have artificially supplied nutrition and hydration. You can also elect to have your healthcare representative or your attorney make this determination for you.
Execution of a living will
You may execute a living will if you are 18 years of age or older.
The living will must be:
A living witness may not be:
You should notify your physician about the living will. Your physician will then place a copy of it in your medical record. Legally, the living will does not obligate your physician to withhold or withdraw life-prolonging procedures. However, the living will is evidence of your desires and will be given great weight in determining your intent if you are unable to give directions regarding your care. A living will is not in effect during a pregnancy.
Revocation of a living will
You may revoke your living will at any time by:
The revocation is effective when it is communicated to your physician.
The following is approved by the Indiana Code:
4101 living will form
4101 living will form (Spanish)