Patient Forms

---

Advance Directives

Each individual has the right to direct his or her own care. Current information about Advanced Directives and Indiana state forms can be found on the Indiana State Department of Health website.

Forms included, but not limited to, include:

• Health Care Representative Appointment
• Life Prolonging Procedures Declaration
• Living Will Declaration (English and Spanish versions)
• Out-of-hospital Do Not Resuscitate Declaration and Order

Learn more at the Indiana State Department of Health website

Parental Consent

If you're traveling and have to leave your children in the care of someone else, be sure they're protected. Always leave written authorization so your children can receive medical treatment, if needed.

Simply download the form below, fill it out and leave it with your children's caregiver. An authorized form is valid for one year following the signature date unless the form has been withdrawn with written consent.

Delegation of Authority to Treat Minors Consent Form (PDF).
Instructions for the completion of the Delegation of Authority to Treat Minors Consent Form (PDF).

Patient Registration and Information Form

• Authorization for Release of Health Information

Warsaw Patients

Download the new patient packet:

• Patient Consent for E-Prescribing
• Information Disclosure Authorization
• New Patient Medical History Questionnaire
• Patient Registration Form
• Notice of Communication Accessibility Services
• Race and Ethnicity Form
• Notice of Privacy Practices