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DESIGNATION OF HEALTH CARE SURROGATE
I, ________________________, designate as my health care surrogate under S. 765.202, Florida Statutes:
If my health care surrogate is not willing, able, or reasonably available to perform his or her duties, I
designate as my alternate health care surrogate:
INSTRUCTIONS FOR HEALTH CARE
I authorize my health care surrogate to: (Initials required in blank spaces below.)
_______ Receive any of my health information, whether oral or recorded in any form or medium, that:
1. Is created or received by a health care provider, health care facility, health plan, public health,
employer, life insurer, school or university, or health care clearinghouse; and
2. Relates to my past, present, or future physical or mental health or condition; the provision of
health care to me; or the past, present, or future payment for the provision of health care to me.
I further authorize my health care surrogate to:
_______ Make all health care decisions for me, which means he or she has the authority to:
3. Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my
health care, including life-prolonging procedures.
4. Apply on my behalf for private, public, government, or veteran’s benefits to defray the cost of
5. Access my health information reasonably necessary for the health care surrogate to make
decisions involving my health care and to apply for benefits for me.
_______6. Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes.