Revocation of Declaration of Mental Health Care Treatment - Indiana 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the space provided for the Declarant. This identifies you as the individual revoking the declaration.
3. Fill in the date when you originally executed the Declaration for Mental Health Treatment. This is crucial for legal clarity.
4. In the section stating your right to withdraw consent, ensure that you understand this right as per IC 16-36-1.5-10, reinforcing your autonomy over treatment decisions.
5. Complete the date field at the bottom of the form where you are signing this revocation, ensuring it reflects when you are officially withdrawing consent.
6. Sign and print your name in the designated areas to validate your revocation. Also, provide your address for identification purposes.

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