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Florida ___________________________________ -2- _________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ___________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _____________________________________ Address: __________________________________________________________________ Signed: ____________________________________________________________________ Dated: _______________me: ____________________________________________________________________ Address: __________________________________________________________________ Name: _____________________________________________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. Na_______________________________________________________ ____________________________________________________________________________ -1- I further affirm that this designation is not being made as a Instructions (optional): ____________________________________________________________________________ ____________________________________________________________________________ _____________________ovide, withhold, or withdraw consent on my behalf; 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 ly understand that this designation will permit my designee to make health care decisions, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law, and to pr_________________________________________ ______________________________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ I fuling or unable to perform his or her duties, I wish to designate as my alternate surrogate: Name: ____________________________________________________________________ Address: ______________________________________________ ______________________________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ If my surrogate is unwilledures, I wish to designate as my surrogate for health care decisions: Name: ____________________________________________________________________ Address: _______________________________________________________________________ (Last, First, Middle Initial) In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Designation of Health Care Surrogate Name: ______________________rticular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax y be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your pato their legal effect or completeness. [_]These forms are 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 onll's health care status to the guardian. [_] These forms 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 lth care decisions for the principal, unless the court has modified or revoked the authority of the surrogate pursuant to s. 744.3115. The surrogate may be directed by the court to report the principafrom a health care facility or other facility or program licensed under chapter 400. (3) If, after the appointment of a surrogate, a court appoints a guardian, the surrogate shall continue to make heaelease of information and medical records to appropriate persons to ensure the continuity of the principal's health care and may authorize the admission, discharge, or transfer of the principal to or health care provider or facility may not, however, make such application a condition of continued care if the principal, if capable, would have refused to apply. (2) The surrogate may authorize the rh as Medicare and Medicaid, for the principal and have access to information regarding the principal's income and assets and banking and financial records to the extent required to make application. Aiate form whenever consent is required, including a physician's order not to resuscitate. (d) Be provided access to the appropriate medical records of the principal. (e) Apply for public benefits, sucay consider the patient's best interest in deciding that proposed treatments are to be withheld or that treatments currently in effect are to be withdrawn. (c) Provide written consent using an approprelieves the principal would have made under the circumstances if the principal were capable of making such decisions. If there is no indication of what the principal would have chosen, the surrogate mduring the principal's incapacity. (b) Consult expeditiously with appropriate health care providers to provide informed consent, and make only health care decisions for the principal which he or she bpal's instructions, unless such authority has been expressly limited by the principal, shall: -2- (a) Have authority to act for the principal and to make all health care decisions for the principal g lifeprolonging procedures, the provisions of part III shall apply. Florida Statutes Title 44 Chapter 765 Section 205: Responsibility of the surrogate (1) The surrogate, in accordance with the princi make health care decisions shall not be construed as a finding that a principal lacks capacity for any other purpose. 5) In the event the surrogate is required to consent to withholding or withdrawinall cease, but shall recommence if the principal subsequently loses capacity as determined pursuant to this section. 4) A determination made pursuant to this section that a principal lacks capacity to's spouse or adult children of the principal's designation of the surrogate. In the event the attending physician determines that the principal has regained capacity, the authority of the surrogate sh in effect until a determination that the principal has regained such capacity. Upon commencement of the surrogate's authority, a surrogate who is not the principal's spouse shall notify the principalided in chapter 709 or Chapter 765 Section 203. 3) The surrogate's authority shall commence upon a determination under subsection (2) that the principal lacks capacity, and such authority shall remain to an attorney in fact under a durable power of attorney, the facility shall notify such surrogate or attorney in fact in writing that her or his authority under the instrument has commenced, as provre facility shall enter both physician's evaluations in the principal's medical record. If the principal has designated a health care surrogate or has delegated authority to make health care decisionshysician shall also evaluate the principal's capacity, and if the second physician agrees that the principal lacks the capacity to make health care decisions or provide informed consent, the health caan concludes that the principal lacks capacity, enter that evaluation in the principal's medical record. If the attending physician has a question as to whether the principal lacks capacity, another principal's capacity to make health care decisions for herself or himself or provide informed consent is in question, the attending physician shall evaluate the principal's capacity and, if the physicie or he is determined to be incapacitated. Incapacity may not be inferred from the person's voluntary or involuntary hospitalization for mental illness or from her or his mental retardation. 2) If a psurrogate. Florida Statutes Title 44 Chapter 765 Section 204: Capacity of principal; procedure 1) A principal is presumed to be capable of making health care decisions for herself or himself unless sh-1- (7) A written designation of a health care surrogate executed pursuant to this section establishes a rebuttable presumption of clear and convincing evidence of the principal's designation of the he principal's choice to make decisions regarding mental health treatment. (6) Unless the document states a time of termination, the designation shall remain in effect until revoked by the principal. e document designating the health care surrogate expressly states otherwise, the court shall assume that the health care surrogate authorized to make health care decisions under this chapter is also t that the principal is determined by a court to be incompetent to consent to mental health treatment and a guardian advocate is appointed as provided under Chapter 394 Section 4598. However, unless th's instructions, the health care facility may seek the appointment of a proxy pursuant to part IV. (5) A principal may designate a separate surrogate to consent to mental health treatment in the eventgnation. (4) If neither the designated surrogate nor the designated alternate surrogate is able or willing to make health care decisions on behalf of the principal and in accordance with the principal as surrogate for the principal if the original surrogate is unwilling or unable to perform his or her duties. The principal's failure to designate an alternate surrogate shall not invalidate the desi blood relative. (3) A document designating a health care surrogate may also designate an alternate surrogate provided the designation is explicit. The alternate surrogate may assume his or her dutiesated as surrogate shall not act as witness to the execution of the document designating the health care surrogate. At least one person who acts as a witness shall be neither the principal's spouse nornt may, in the presence of witnesses, direct that another person sign the principal's name as required herein. An exact copy of the instrument shall be provided to the surrogate. (2) The person designument designating a surrogate to make health care decisions for a principal shall be signed by the principal in the presence of two subscribing adult witnesses. A principal unable to sign the instrumerom the Florida Statutes relating to the Florida Designation of Health Care Surrogate Form. Florida Statutes Title 44 Chapter 765 Section 202: Designation of a health care surrogate. (1) A written docSurrogate (Power of Attorney for Health Care) Form. This Florida Designation of Health Care Surrogate is based on Florida Statutes Title 44 Chapter 765 Section 203. The following are useful excerpts fre Surrogate (Power of Attorney for Health Care) including excerpts from the Florida Statutes relating to the Florida Designation of Health Care Surrogate Form; (2) Florida Designation of Health Care Information and Instructions Florida Designation of Health Care Surrogate (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Florida Designation of Health Ca Florida