Indiana POST: State Form 55317

Indiana patients who are qualified persons under IC 16-36-6, with an advanced chronic progressive illness or frailty or a terminal condition, can have their scope-of-treatment choices written as a physician's order. After a discussion, the treating clinician records CPR status, comfort, limited or full interventions, antibiotic use and artificial nutrition. Both pages must be present, and the original is the patient's personal property.

Who completes it

The treating physician, APRN or PA determines the patient qualifies, completes Sections A through D and signs Section H. The patient, legal representative or proxy signs Section E, with contact details in Section F.

Submitting and payment

How to submit it
Nothing is filed with the state; the patient keeps the original, and fax, paper or electronic copies are valid.

Good to know

  • Under HEA 1458 (2023), a proxy may sign when there is no legally appointed health care representative.
  • Section A is required; any other section left blank implies full treatment for that section.
  • Section G documents who took part in the discussion, such as the patient, health care representative, guardian, parent of a minor or proxy.
  • The current version is State Form 55317 (R6 / 6-23), distributed through the Indiana Patient Preferences Coalition.

Get the official form

Download the current version from the source each time; forms change without notice.

Indiana Physician Orders for Scope of Treatment (POST)

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign an Indiana POST form?

Only the individual's treating physician, APRN or physician assistant may execute a POST, after determining the person is a qualified person and the orders are reasonable and medically appropriate. The patient, legal representative or proxy must also sign and date the form for it to be effective.

Who qualifies for an Indiana POST?

A qualified person has an advanced chronic progressive illness or frailty, a condition from which there can be no recovery and death will occur within a short period without life-prolonging procedures, or a condition where resuscitation would be unsuccessful or followed by repeated arrest.