Free Printable Health Care Surrogate Form If i initial this box my health care surrogate s authority to make health care decisions for me takes effect immediately pursuant to section 765 204 3 florida states any instructions of health care decisions i make either verbally or in writing while i possess capacity shall supercede any instructions or health care decisions
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 further authorize my health care surrogate to Make all health care decisions for me which means he or she has the authority to 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 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
Free Printable Health Care Surrogate Form
Free Printable Health Care Surrogate Form
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Designation Of Health Care Surrogate Florida Printable Form
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This health care surrogate designation form will help the healthcare team speak to the person you trust to speak on your behalf when you are no longer able to effectively participate in decision making for yourself It is a good idea to give copies to your health care surrogate s and or physicians Declaration made this day of 2 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 if at any time I am incapacitated and or or I have a terminal condition I have an end stage condition I am in a persistent vegetative state
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 Designate a health care surrogate The first step toward formalizing your family care plan is to execute health care surrogate designations A health care surrogate designation is a legal document that appoints a person to become your surrogate if you become incapacitated Incapacity is defined as the physical or mental inability to
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Designation Of Health Care Surrogate Florida Printable Form
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A Florida designation of health care surrogate nominates a surrogate trusted individual to make medical decisions for the person that completes the form the principal It is the official state form created by the Florida Bar and Florida Medical Association and referred to as a medical power of attorney When writing the document the principal can nominate another surrogate Begin by entering the Health Care Surrogate s Work Number on the blank line labeled Phone w and his or her Home Phone Number on the blank line labeled h below this Below the Health Care Surrogate s Name enter the Physical Address where he or she lives on the Address line
The forms included on the Florida Agency for Health Care Administration s Health Care Advance Directives Consumer Guide scroll down to find the downloadable forms have been approved by the Supreme Court of Florida Neither the Supreme Court of Florida nor The Florida Bar expresses an opinion as to whether the forms comport with current law 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
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If i initial this box my health care surrogate s authority to make health care decisions for me takes effect immediately pursuant to section 765 204 3 florida states any instructions of health care decisions i make either verbally or in writing while i possess capacity shall supercede any instructions or health care decisions
https://www.fhcp.com/documents/forms/Advanced-Directives-Designation-of-Health-Care-Surrogate.pdf
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 further authorize my health care surrogate to Make all health care decisions for me which means he or she has the authority to
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Free Printable Health Care Surrogate Form - 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
