Fillable Designation of Health Care Surrogate

Fill Online, Printable, Fillable, Blank Designation of Health Care Surrogate Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Designation of Health Care Surrogate

On average this form takes 5 minutes to complete

The Designation of Health Care Surrogate form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 19 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
02/04
Suggested form of a Health Care Surrogate, Florida Statutes Section 765.203
Designation of Health Care Surrogate
Name
In the event I have been determined to be incapacitated to provide informed consent for medical treatment and
surgical and diagnostic procedures, I wish to designate, as my surrogate for health care decisions:
Name
Street Address
City State Zip
Phone
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:
Name
Street Address
City State Zip
Phone
I fully understand that this designation will permit my designee to make health care decisions and to provide,
withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of health care; and to
authorize my admission to or transfer from a health care facility
Additional Instructions (optional):
I further affirm that this designation is not being made as a condition of treatment or admission to a health care
facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they
may know who my surrogate is.
Name
Name
Signed:
Witnesses 1.
2.
At least one witness must not be a husband or wife or a blood relative of the principal.
— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —
LIVING WILLS AND HEALTH CARE ADVANCE DIRECTIVES: FAQs
The Florida Legislature has recognized that every competent adult has the fundamental right of self-
determination regarding decisions pertaining to his or her own health, including the right to choose or
refuse medical treatment or procedures which would only prolong life when a terminal condition exists.
This right, however, is subject to certain interests of society, such as the protection of human life and
the preservation of ethical standards in the medical profession. To ensure that this right is not lost or
diminished by virtue of later physical or mental incapacity, the Legislature has established a procedure
within Florida Statutes Chapter 765 allowing a person to plan for incapacity, and if desired, to designate
another person to act on his or her behalf and make necessary medical decisions upon such
incapacity.
What is a Living Will?
Every competent adult has the right to make a written declaration commonly known as a "Living Will."
The purpose of this document is to direct the provision, the withholding or withdrawal of life prolonging
procedures in the event one should have a terminal condition. The suggested form of this instrument
has been provided by the Legislature within Florida Statutes Section 765.303. In Florida, the definition
of "life prolonging procedures" has been expanded by the Legislature to include the provision of food
and water to terminally ill patients.
What is the difference between a Living Will and a legal will?
A Living Will should not be confused with a person’s legal will, which disposes of personal property on
or after his or her death, and appoints a personal representative or revokes or revises another will.
How do I make my Living Will effective?
Under Florida law, a Living Will must be signed by its maker in the presence of two witnesses, at least
one of whom is neither the spouse nor a blood relative of the maker. If the maker is physically unable to
sign the Living Will, one of the witnesses can sign in the presence and at the direction of the maker.
Florida will recognize a Living Will, which has been signed in another state, if that Living Will was
signed in compliance with the laws of that state, or in compliance with the laws of Florida.
After I sign a Living Will, what is next?
Once a Living Will has been signed, it is the maker's responsibility to provide notification to the
physician of its existence. It is a good idea to provide a copy of the Living Will to the maker's physician
and hospital, to be placed within the medical records.
What is a Health Care Surrogate?
Any competent adult may also designate authority to a Health Care Surrogate to make all health care
decisions during any period of incapacity. During the maker's incapacity, the Health Care Surrogate has
the duty to consult expeditiously, with appropriate health care providers. The Surrogate also provides
informed consent and makes only health care decisions for the maker, which he or she believes the
maker would have made under the circumstances if the maker were capable of making such decisions.
If there is no indication of what the maker would have chosen, the Surrogate may consider the maker's
best interest in deciding on a course of treatment. The suggested form of this instrument has been
provided by the Legislature within Florida Statutes Section 765.203.
How do I designate a Health Care Surrogate?
Under Florida law, designation of a Health Care Surrogate should be made through a written document,
and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor
a blood relative of the maker. The person designated as Surrogate cannot act as a witness to the
signing of the document.
Can I have more than one Health Care Surrogate?
The maker can also explicitly designate an Alternate Surrogate. The Alternate Surrogate may assume
the duties as Surrogate if the original Surrogate is unwilling or unable to perform his or her duties. If the
maker is physically unable to sign the designation, he or she may, in the presence of witnesses, direct
that another person sign the document. An exact copy of the designation must be provided to the
Health Care Surrogate. Unless the designation states a time of termination, the designation will remain
in effect until revoked by its maker.
Can the Living Will and the Health Care Surrogate designation be revoked?
Both the Living Will and the Designation of Health Care Surrogate may be revoked by the maker at any
time by a signed and dated letter of revocation; by physically canceling or destroying the original
document; by an oral expression of one's intent to revoke; or by means of a later executed document
which is materially different from the former document. It is very important to tell the attending physician
that the Living Will and Designation of Health Care Surrogate has been revoked.
Where can I go to obtain legal advice on this issue?
If you believe you need legal advice, call your attorney. If you do not have an attorney, call The Florida
Bar Lawyer Referral Service at 1-800-342-8011, or the local lawyer referral service or legal aid office
listed in the yellow pages of your telephone book.
This information has been prepared by the Consumer Protection Law Committee of The
Florida Bar and the Bar’s Public Information Office and is offered as a courtesy of The Florida
Bar and the Florida Medical Association.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Designation of Health Care Surrogate

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 September 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document