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Florida Phone: _______________________________________ 2 ____________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ __ (Declarant's Signature) _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______ ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________ _______________________________________________________________________________________ I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional Instructions (optional): ________________________________________________________________________________________ ______________________________________ Zip Code: ___________________________ Phone: _____________________________________________________arry out the provisions of this declaration should my surrogate be unwilling or unable to act on my behalf: 1 Name: ____________________________________________________________________ Address: ________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ I wish to designate the following person as my alternate surrogate, to cs of this declaration: Name: ____________________________________________________________________ Address: __________________________________________________________________ __________________________ be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisiony my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event that I have been determined tohe administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain. It is my intention that this declaration be honored bolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only tal) and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that lifepr if at any time I am incapacitated and _________ I have a terminal condition; or (initial) _________ I have an end-stage condition; or (initial) _________ I am in a persistent vegetative state (initif _____, ______ (year), I, __________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will Declaration made this _____ day o sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shouldnd/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to makeanties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal astate. (c) Any limitations or conditions expressed orally or in a written declaration have been carefully considered and satisfied. [_] These forms are provided "as is" and no implied or express warrability of recovering capacity so that the right could be exercised directly by the principal. (b) The principal has a terminal condition, has an end-stage condition, or is in a persistent vegetative tions. Information & Instructions ­ Page 4 (2) Before proceeding in accordance with the principal's living will, it must be determined that: (a) The principal does not have a reasonable medical probnot sought within 7 days following the attending physician's decision to withhold or withdraw life-prolonging procedures, the attending physician may proceed in accordance with the principal's instrucithdraw life-prolonging procedures, the attending physician shall not withhold or withdraw life-prolonging procedures pending review under s. Ch765. Section 105. If a review of a disputed decision is r part II, the attending physician may proceed as directed by the principal in the living will. In the event of a dispute or disagreement concerning the attending physician's decision to withhold or wexpressing his or her desires concerning lifeprolonging procedures, but has not designated a surrogate to execute his or her wishes concerning life-prolonging procedures or designated a surrogate unde rebuttable presumption of clear and convincing evidence of the principal's wishes. Florida Statutes Title 44 Chapter 765 Section 304: Procedure for living will (1) If a person has made a living will care facility which is so notified shall promptly make the living will or a copy thereof a part of the principal's medical records. (3) A living will, executed pursuant to this section, establishes athe principal is admitted to a health care facility, any other person may notify the physician or health care facility of the existence of the living will. An attending or treating physician or health principal to provide for notification to her or his attending or treating physician that the living will has been made. In the event the principal is physically or mentally incapacitated at the time ysically unable to sign the living will, one of the witnesses must subscribe the principal's signature in the principal's presence and at the principal's direction. (2) It is the responsibility of theetative state. A living will must be signed by the principal in the presence of two subscribing witnesses, one of whom is neither a spouse nor a blood relative of the principal. If the principal is pharation and direct the providing, withholding, or withdrawal of life-prolonging procedures in the event that such person has a terminal condition, has an end-stage condition, or is in a persistent vego Living Wills. Florida Statutes Title 44 Chapter 765 Section 302: Procedure for making a living will; notice to physician. (1) Any competent adult may, at any time, make a living will or written declFlorida Living Will. This Florida Living Will is based on Florida Statutes Title 44 Chapter 765 Section 303. For your convenience, we have included useful excerpts from the Florida Statutes relating tion and Instructions Florida Living Will This package contains (1) Information and Instruction for Florida Living Will, including excerpts from the Florida Statutes relating to Living Will Forms; (2) ______________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ -2- Informat____________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ ________________________________________________________________________ Signed: ____________________________________________________________________ Dated: ______________________________ ______________________________________________________ Address: __________________________________________________________________ Name: ____________________________________________________________________ Address: _________________e 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: ___________________________________________________ ____________________________________________________________________________ -1- I further affirm that this designation is not being made as a condition of treatment or admission to a health car__________________________________________________ ____________________________________________________________________________ ________________________________________________________________________to 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): __________________________designee to make health care decisions, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law, and to provide, withhold, or withdraw consent on my behalf; ____________________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ I fully understand that this designation will permit my o designate as my alternate surrogate: Name: ____________________________________________________________________ Address: __________________________________________________________________ _________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ If my surrogate is unwilling or unable to perform his or her duties, I wish t care decisions: Name: ____________________________________________________________________ Address: __________________________________________________________________ _______________________________l) In the event that 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 healthis subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Designation of Health Care Surrogate Name: ________________________________________________ (Last, First, Middle Initiay whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms ithout consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorneare not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used w are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their lega l effect or completeness. [_]These forms as modified or revoked the authority of the surrogate pursuant to s. 744.3115. The surrogate may be directed by the court to report the principal's health care status to the guardian. [_] These forms licensed under chapter 400. (3) If, after the appointment of a surrogate, a court appoints a guardian, the surrogate shall continue to make health care decisions for the principal, unless the court h persons to ensure the continuity of the principal's health care and may authorize the admission, discharge, or transfer of the principal to or from a health care facility or other facility or program such application a condition of continued care if the principal, if capable, would have refused to apply. (2) The surrogate may authorize the release of information and medical records to appropriateccess to information regarding the principal's income and assets and banking and financial records to the extent required to make application. A health care provider or facility may not, however, makeician's order not to resuscitate. (d) Be provided access to the appropriate medical records of the principal. (e) Apply for public benefits, such as Medicare and Medicaid, for the principal and have a proposed treatments are to be withheld or that treatments currently in effect are to be withdrawn. (c) Provide written consent using an appropriate form whenever consent is required, including a physances if the principal were capable of making such decisions. If there is no indication of what the principal would have chosen, the surrogate may consider the patient's best interest in deciding thatusly with appropriate health care providers to provide informed consent, and make only health care decisions for the principal which he or she believes the principal would have made under the circumstssly limited by the principal, shall: -2- (a) Have authority to act for the principal and to make all health care decisions for the principal during the principal's incapacity. (b) Consult expeditiohall apply. Florida Statutes Title 44 Chapter 765 Section 205: Responsibility of the surrogate (1) The surrogate, in accordance with the principal's instructions, unless such authority has been exprending that a princ ipal lacks capacity for any other purpose. 5) In the event the surrogate is required to consent to withholding or withdrawing lifeprolonging procedures, the provisions of part III stly loses capacity as determined pursuant to this section. 4) A determination made pursuant to this section that a principal lacks capacity to make health care decisions shall not be construed as a fi of the surrogate. In the event the attending physician determines that the principal has regained capacity, the authority of the surrogate shall cease, but shall recommence if the principal subsequengained such capacity. Upon commencement of the surrogate's authority, a surrogate who is not the principal's spouse shall notify the principal's spouse or adult children of the principal's designationrogate's authority shall commence upon a determination under subsection (2) that the principal lacks capacity, and such authority shall remain in effect until a determination that the principal has re the facility shall notify such surrogate or attorney in fact in writing that her or his authority under the instrument has commenced, as provided in chapter 709 or Chapter 765 Section 203. 3) The sure principal's medical record. If the principal has designated a health care surrogate or has delegated authority to make health care decisions to an attorney in fact under a durable power of attorney, if the second physician agrees that the principal lacks the capacity to make health care decisions or provide informed consent, the health care facility shall enter both physician's evaluations in th evaluation in the principal's medical record. If the attending physician has a question as to whether the principal lacks capacity, another physician shall also evaluate the principal's capacity, andelf or himself or provide informed consent is in question, the attending physician shall evaluate the principal's capacity and, if the physician concludes that the principal lacks capacity, enter thatnot be inferred from the person's voluntary or involuntary hospitalization for mental illness or from her or his mental retardation. 2) If a principal's capacity to make health care decisions for hers04: Capacity of principal; procedure 1) A principal is presumed to be capable of making health care decisions for herself or himself unless she or he is determined to be incapacitated. Incapacity may xecuted pursuant to this section establishes a rebuttable presumption of clear and convincing evidence of the principal's designation of the surrogate. Florida Statutes Title 44 Chapter 765 Section 2alth treatment. (6) Unless the document states a time of termination, the designation shall remain in effect until revoked by the principal. -1- (7) A written designation of a health care surrogate estates otherwise, the court shall assume that the health care surrogate authorized to make health care decisions under this chapter is also the principal's choice to make decisions regarding mental heent to consent to mental health treatment and a guardian advocate is appointed as provided under Chapter 394 Section 4598. However, unless the document designating the health care surrogate expressly intment of a proxy pursuant to part IV. (5) A principal may designate a separate surrogate to consent to mental health treatment in the event that the principal is determined by a court to be incompetsignated alternate surrogate is able or willing to make health care decisions on behalf of the principal and in accordance with the principal's instructions, the health care facility may seek the appos unwilling or unable to perform his or her duties. The principal's failure to designate an alternate surrogate shall not invalidate the designation. (4) If neither the designated surrogate nor the deurrogate may also designate an alternate surrogate provided the designation is explicit. The alternate surrogate may assume his or her duties as surrogate for the principal if the original surrogate i of the document designating the health care surrogate. At least one person who acts as a witness shall be neither the principal's spouse nor blood relative. (3) A document designating a health care serson sign the principal's name as required herein. An exact copy of the instrument shall be provided to the surrogate. (2) The person designated as surrogate shall not act as witness to the execution for a principal shall be signed by the principal in the presence of two subscribing adult witnesses. A principal unable to sign the instrument may, in the presence of witnesses, direct that another p of Health Care Surrogate Form. Florida Statutes Title 44 Chapter 765 Section 202: Designation of a health care surrogate. (1) A written document designating a surrogate to make health care decisionsrida Designation of Health Care Surrogate is based on Florida Statutes Title 44 Chapter 765 Section 203. The following are useful excerpts from the Florida Statutes relating to the Florida Designationxcerpts from the Florida Statutes relating to the Florida Designation of Health Care Surrogate Form; (2) Florida Designation of Health Care Surrogate (Power of Attorney for Health Care) Form. This Floare Surrogate (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Florida Designation of Health Care Surrogate (Power of Attorney for Health Care) including eith a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Florida Designation of Health Cour particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed we. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits y made or are provided as to their suitability for any specific purpose or as to their legal effect or completene ss. [_]These forms are not intended and are not a substitute for legal and/or tax adviclth Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have beenFlorida Advance Health Care Directive This package contains both a Florida Power of Attorney for Health Care and a Florida Living Will. Together these forms are also sometimes known as an Advance Hea Florida