⇨

Blank Florida Health Care Surrogate PDF Form

The Florida Health Care Surrogate form is a legal document that allows individuals to designate someone they trust to make health care decisions on their behalf in the event they become unable to do so. This form ensures that your health care preferences are respected and that a trusted person is empowered to act in your best interests. It is essential to complete this form thoughtfully, as it can provide peace of mind and clarity during challenging times.

If you are ready to take this important step, please fill out the form by clicking the button below.

Blank Florida Health Care Surrogate PDF Form

Article Guide

The Florida Health Care Surrogate form is a crucial document that allows individuals to appoint someone to make medical decisions on their behalf in the event they become unable to do so. This form includes essential information such as the names, phone numbers, and addresses of both the designated health care surrogate and an alternate surrogate. It grants the surrogate the authority to access health information, make informed consent decisions, and apply for benefits related to health care costs. Additionally, the form contains space for specific instructions and restrictions, ensuring that the principal's wishes are respected. Importantly, while the individual retains decision-making capacity, their preferences take precedence, and the surrogate must keep them informed about decisions made on their behalf. The authority of the health care surrogate becomes effective only when a primary physician determines that the individual can no longer make their own health care decisions, although immediate authority can be granted if desired. This form is a powerful tool for ensuring that health care decisions align with personal values and preferences, providing peace of mind for both the individual and their loved ones.

Document Preview

765.203 – Suggested form of designation – a written designation of a Health Care Surrogate executed pursuant to this chapter may, but need not be, in the following form.

DESIGNATION OF HEALTH CARE SURROGATE

I, _____________________________________________, designate as my health care surrogate under

§ 765.202, Florida statutes:

Name: ________________________________________Phone:_____________________________

Address: _________________________________________________________________________

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:

Name: ________________________________________Phone:_____________________________

Address: _________________________________________________________________________

INSTRUCTIONS FOR HEALTH CARE

I authorize my health care surrogate to: (Initials required in the 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 authority, 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: (Initials required in the blank space below.)

_______ Make all health care decisions for me, which means he or she has the authority to:

1.Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care, including life-prolonging procedures.

2.Apply on my behalf for private, public, government, or veteran’s benefits to defray the cost of health care.

3.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.

4.Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes.

_______ Specific instructions and restrictions: (Initials required in the blank space.)

______________________________________________________________________________________

While I have decisionmaking capacity, my wishes are controlling and my physicians and health care providers must clearly communicate to me the treatment plan or any change to the treatment plan prior to its implementation.

To the extent that I am capable of understanding, my health care surrogate shall keep me reasonably informed of all decisions that he or she has made on my behalf and matters concerning me.

THIS HEALTH CARE SURROGATE DESIGNATION IS NOT AFFECTED BY MY SUBSEQUENT INCAPACITY EXCEPT AS PROVIDED IN CHAPTER 765, FLORIDA STATUTES.

PURSUANT TO SECTION 765.104, FLORIDA STATUTES, I UNDERSTAND THAT I MAY, AT ANY TIME WHILE I RETAIN MY CAPACITY, REVOKE OR AMEND THIS DESIGNATION BY:

1.SIGNING A WRITTEN AND DATED INSTRUMENT WHICH EXPRESSES MY INTENT TO AMEND OR REVOKE THIS DESIGNATION;

2.PHYSICALLY DESTROYING THIS DESIGNATION THROUGH MY OWN ACTION OR BY THAT OF ANOTHER PERSON IN MY PRESENCE AND UNDER MY DIRECTION;

3.VERBALLY EXPRESSING MY INTENTION TO AMEND OR REVOKE THIS DESIGNATION; OR

4.SIGNING A NEW DESIGNATION THAT IS MATERIALLY DIFFERENT FROM THIS DESIGNATION.

MY HEALTH CARE SURROGATE’S AUTHORITY BECOMES EFFECTIVE WHEN MY PRIMARY PHYSICIAN DETERMINES THAT I AM UNABLE TO MAKE MY OWN HEALTH CARE DECISIONS UNLESS I INITIAL EITHER OR BOTH OF THE FOLLOWING BOXES:

IF I INITIAL THIS BOX [_______] MY HEALTH CARE SURROGATE’S AUTHORITY TO RECEIVE

MY HEALTH INFORMATION TAKES EFFECT IMMEDIATELY.

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 MADE BY MY SURROGATE THAT ARE IN MATERIAL CONFLICT WITH THOSE MADE BY ME.

Signature: Sign and date the form here:

_________________ ______________________________ _______________________________

DateSignaturePrinted Name

_________________________________________________________________________________

Address

Signatures of Witnesses:

Witness:_________________________________ Witness:_________________________________

Printed Name: ____________________________ Printed Name: ____________________________

Address: ________________________________ Address: ________________________________

_________________________________________________________________

Phone: _________________________________ Phone: ___________________________________

➤ PDF File

Form Specifications

Fact Name	Details
Governing Law	The Florida Health Care Surrogate form is governed by Chapter 765 of the Florida Statutes.
Designation Requirement	The form allows individuals to designate a health care surrogate, who will make medical decisions on their behalf if they become incapacitated.
Alternate Surrogate	Individuals can also name an alternate health care surrogate in case the primary surrogate is unavailable or unwilling to act.
Health Information Access	The surrogate is authorized to receive all health information necessary for making informed decisions about the individual's care.
Decision-Making Authority	The surrogate has the authority to provide consent or refusal for any health care treatments, including life-prolonging procedures.
Revocation of Designation	Individuals can revoke or amend their designation at any time while they retain decision-making capacity through various means, including a written instrument or verbal expression.
Effective Date of Authority	The surrogate's authority becomes effective only when a primary physician determines that the individual is unable to make their own health care decisions.
Conflicting Instructions	Any health care decisions made by the individual while they have capacity will take precedence over those made by the surrogate if there is a conflict.

Florida Health Care Surrogate: Usage Guidelines

Completing the Florida Health Care Surrogate form is an important step in designating someone to make health care decisions on your behalf. This process requires careful attention to detail to ensure that your wishes are clearly communicated and legally recognized.

Begin by filling in your name at the top of the form where indicated.
Designate your health care surrogate by providing their name, phone number, and address in the designated spaces.
If you wish to name an alternate health care surrogate, fill in their name, phone number, and address in the appropriate section.
In the instructions for health care section, initial the blank space to authorize your surrogate to receive your health information.
Initial the blank space to authorize your surrogate to make health care decisions on your behalf.
If you have specific instructions or restrictions, write them in the space provided and initial it.
Indicate your wishes regarding decision-making capacity. Initial the boxes if you want your surrogate’s authority to receive health information or make decisions to take effect immediately.
Sign and date the form at the bottom where indicated.
Have two witnesses sign the form. Each witness must also print their name and provide their address.

Your Questions, Answered

What is the Florida Health Care Surrogate form?

The Florida Health Care Surrogate form is a legal document that allows an individual to designate someone else to make health care decisions on their behalf in the event that they become unable to do so. This form is particularly important for individuals who want to ensure that their health care preferences are respected, even when they cannot communicate them. It empowers a trusted person, known as a health care surrogate, to make informed decisions regarding medical treatment, access health information, and manage health-related benefits.

How do I complete the Florida Health Care Surrogate form?

To complete the form, you will need to fill in your name, the name of your designated health care surrogate, and their contact information. Additionally, you can designate an alternate surrogate in case your primary choice is unavailable. The form also requires your initials in specific sections to grant your surrogate the authority to receive health information and make health care decisions on your behalf. It is essential to read the instructions carefully and ensure that your wishes are clearly expressed. Once completed, sign and date the form in the designated area, and have it witnessed by two individuals who are not related to you or who will not benefit from your estate.

When does the authority of my health care surrogate take effect?

Your health care surrogate's authority typically becomes effective when your primary physician determines that you are unable to make your own health care decisions. However, you have the option to allow your surrogate’s authority to take effect immediately by initialing the appropriate box on the form. This flexibility ensures that you can tailor the arrangement to suit your specific needs and preferences.

Can I revoke or change my Health Care Surrogate designation?

Yes, you can revoke or change your Health Care Surrogate designation at any time while you still have decision-making capacity. This can be done by signing a new document that expresses your intent to amend or revoke the designation, physically destroying the existing document, or verbally communicating your wishes. It is crucial to ensure that any changes are documented appropriately to avoid confusion regarding your health care preferences.

What if my health care surrogate and I have conflicting wishes regarding my care?

If you possess decision-making capacity, your wishes will always take precedence over those of your health care surrogate. This means that any verbal or written instructions you provide while you are capable will override any decisions made by your surrogate that conflict with your wishes. This provision is designed to ensure that your autonomy and preferences are respected, even when a surrogate is involved in your health care decisions.

Common mistakes

Not providing complete information. Ensure that all sections of the form are filled out, including names, phone numbers, and addresses for both the health care surrogate and any alternate surrogates.
Failing to initial required sections. Remember to initial each section where indicated. This indicates your consent for your surrogate to act on your behalf.
Not specifying alternate surrogates. If your primary surrogate is unavailable, having an alternate can prevent delays in decision-making.
Ignoring specific instructions. If you have specific wishes regarding your health care, write them down clearly in the designated area.
Not understanding the authority granted. Make sure you know what decisions your surrogate can make on your behalf. This includes health care decisions and access to your health information.
Not revoking the designation when needed. If you change your mind, ensure you follow the correct procedures to revoke or amend your designation.
Forgetting to sign and date the form. Your signature and the date are crucial for the form to be valid. Double-check this before submitting.
Neglecting witness signatures. The form requires signatures from two witnesses. Ensure they sign and provide their printed names and addresses.
Not discussing the designation with the surrogate. It’s important to talk to your surrogate about your wishes and the responsibilities they will take on.

Documents used along the form

When preparing for health care decisions, it's essential to consider various documents that complement the Florida Health Care Surrogate form. Each of these documents serves a unique purpose in ensuring your health care preferences are respected and followed. Here’s a brief overview of some commonly used forms alongside the Health Care Surrogate form.

Living Will: This document outlines your wishes regarding medical treatment in situations where you are unable to communicate your preferences, particularly concerning life-sustaining measures.
Durable Power of Attorney for Health Care: This form allows you to designate someone to make health care decisions on your behalf if you become incapacitated, similar to the Health Care Surrogate form but often broader in scope.
Do Not Resuscitate (DNR) Order: A DNR order specifies that you do not wish to receive CPR or other resuscitative measures in the event of cardiac arrest. It must be signed by a physician.
Anatomical Gift Declaration: This document allows you to express your wishes regarding organ donation after death. It can be included in your Health Care Surrogate form or as a standalone document.
HIPAA Release Form: This form permits designated individuals to access your medical records and health information, ensuring they can make informed decisions regarding your care.
Advance Directive: An advance directive combines elements of a living will and a durable power of attorney, providing comprehensive instructions about your health care preferences and appointing a decision-maker.
Health Care Proxy: Similar to the Health Care Surrogate, a health care proxy designates someone to make health care decisions for you when you are unable to do so, often focusing on specific medical situations.
Patient Advocate Designation: This document allows you to appoint a patient advocate who can help navigate the health care system and ensure your wishes are honored during treatment.

Understanding these documents can empower you to make informed decisions about your health care. It's wise to have these forms in place, as they provide clarity and guidance for your loved ones and medical providers during critical times.

Similar forms

The Florida Health Care Surrogate form has similarities with several other important documents. Each serves a unique purpose but shares the common goal of ensuring that health care decisions align with an individual’s wishes. Here are six documents that are similar:

Durable Power of Attorney: This document allows someone to make financial and legal decisions on your behalf if you become incapacitated. Like the Health Care Surrogate form, it designates a trusted individual to act in your best interests.
Living Will: A Living Will outlines your preferences for medical treatment in situations where you are unable to communicate. It complements the Health Care Surrogate form by providing guidance on your wishes regarding life-prolonging measures.
Do Not Resuscitate (DNR) Order: This order instructs medical personnel not to perform CPR if your heart stops. It aligns with the Health Care Surrogate form by expressing your wishes about emergency medical interventions.
Advance Directive: An Advance Directive combines elements of a Living Will and a Health Care Surrogate designation. It provides a comprehensive plan for your health care preferences and appoints someone to make decisions for you.
Anatomical Gift Declaration: This document allows you to specify your wishes regarding organ donation. It works alongside the Health Care Surrogate form by ensuring your preferences are respected after death.
Health Care Proxy: Similar to the Health Care Surrogate, a Health Care Proxy designates someone to make medical decisions on your behalf. It emphasizes the importance of having a trusted person advocate for you in health care matters.

Dos and Don'ts

When filling out the Florida Health Care Surrogate form, it is important to follow specific guidelines to ensure that the document is valid and reflects your wishes accurately. Below is a list of things to do and avoid during this process.

Do ensure that the form is completed in its entirety, including all required signatures and initials.
Do designate a health care surrogate who you trust to make decisions on your behalf.
Do provide clear and specific instructions regarding your health care preferences.
Do keep a copy of the completed form for your records and share it with your health care surrogate.
Don't leave any blanks in the form; all sections should be filled out appropriately.
Don't designate someone who may not be available or willing to act in your best interest.
Don't forget to have the form witnessed by two individuals who are not related to you or beneficiaries of your estate.

Misconceptions

Misconception 1: The Health Care Surrogate form is only for elderly individuals.

This form can be used by anyone, regardless of age. It’s a proactive way to ensure your health care wishes are respected, no matter your age.

Misconception 2: A Health Care Surrogate can make any decision without limitations.

The surrogate's authority is defined by the instructions you provide. You can specify what decisions they can or cannot make.

Misconception 3: Once the form is signed, it cannot be changed.

You can revoke or amend your designation at any time while you are still capable of making decisions. This flexibility allows you to adapt to changing circumstances.

Misconception 4: The Health Care Surrogate's authority starts immediately upon signing the form.

The authority only becomes effective when your primary physician determines that you are unable to make your own health care decisions, unless you choose otherwise.

Misconception 5: A Health Care Surrogate can override your wishes.

Your wishes take precedence while you are capable of making decisions. Any instructions you give will supersede those of your surrogate.

Misconception 6: The form does not require witnesses.

To be valid, the Health Care Surrogate form must be signed in the presence of witnesses. This adds an extra layer of authenticity to your designation.

Misconception 7: You need a lawyer to complete the Health Care Surrogate form.

The form is designed to be straightforward and can be completed without legal assistance. However, consulting a lawyer can provide peace of mind.

Misconception 8: The Health Care Surrogate form is the same as a living will.

While both documents are important, they serve different purposes. A living will outlines your wishes regarding medical treatment, while the Health Care Surrogate designates someone to make decisions on your behalf.

Key takeaways

When filling out and using the Florida Health Care Surrogate form, consider these key takeaways:

Designate a Surrogate: Clearly name your chosen health care surrogate and provide their contact information.
Include an Alternate: If your primary surrogate is unavailable, designate an alternate surrogate to ensure your health care decisions are managed.
Initial Required Sections: You must initial specific sections to grant your surrogate authority to access health information and make health care decisions.
Understand Your Rights: While you have decision-making capacity, your wishes take precedence over those of your surrogate.
Revocation Process: You can revoke or amend the designation at any time while retaining capacity, through written notice, verbal expression, or destruction of the document.
Effective Authority: The surrogate’s authority becomes effective only when your primary physician determines that you cannot make your own health care decisions.
Witness Signatures: Ensure that the form is signed by two witnesses, as this is a requirement for the designation to be valid.