The Florida Health Care Surrogate form allows individuals to designate someone to make health care decisions on their behalf if they become unable to do so. This important document ensures that your wishes regarding medical treatment are respected and followed, even when you cannot communicate them yourself. If you haven't filled out this form yet, take a moment to do so by clicking the button below.
The Florida Health Care Surrogate form is an essential legal document that empowers individuals to designate someone they trust to make health care decisions on their behalf in the event they become incapacitated. This form allows you to name a primary health care surrogate, along with an alternate, ensuring that your health care preferences are respected even when you cannot communicate them yourself. The form outlines specific instructions, granting the surrogate authority to access your health information, provide informed consent for treatments, and even make decisions regarding life-prolonging procedures. Importantly, it includes provisions for revoking or amending the designation while you retain decision-making capacity, ensuring flexibility as your circumstances change. Additionally, the form clarifies that your wishes take precedence, emphasizing the importance of communication between you, your health care surrogate, and your medical providers. By completing this form, you take a proactive step in managing your health care, ensuring that your values and preferences are honored when it matters most.
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:
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: ___________________________________
Source: The 2016 Florida Statutes, Title XLIV, CIVIL RIGHTS, Chapter 765. Health Care Directives 765.203 Suggested Form of Designation © 1995-2017 The Florida Legislature.
Filling out the Florida Health Care Surrogate form involves a series of steps to ensure that your health care preferences are documented accurately. After completing the form, it is essential to keep a copy for your records and share it with your designated surrogate and healthcare providers.
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 case they become unable to do so. This form ensures that your health care preferences are honored even if you cannot communicate them yourself.
Who can be designated as a health care surrogate?
Any competent adult can be designated as a health care surrogate. This person should be someone you trust to make decisions about your medical care. You can also name an alternate surrogate in case your primary choice is unavailable.
What decisions can my health care surrogate make?
Your health care surrogate has the authority to make a wide range of health care decisions, including:
How does my health care surrogate's authority become effective?
Your surrogate's authority takes effect when your primary physician determines that you are unable to make your own health care decisions. You can also choose to make this authority effective immediately by initialing the appropriate box on the form.
Can I revoke or change my health care surrogate designation?
Yes, you can revoke or amend your designation at any time while you have decision-making capacity. This can be done by signing a new document, verbally expressing your intent, or destroying the original document.
What happens if I have specific instructions or restrictions?
You can include specific instructions and restrictions in the form. Your health care surrogate is required to follow your wishes as long as you are capable of understanding and communicating them.
Do I need witnesses to sign the form?
Yes, the Florida Health Care Surrogate form must be signed in the presence of two witnesses. These witnesses should not be related to you or have any financial interest in your estate.
Is this form affected by my incapacity?
No, once you designate a health care surrogate, that designation remains effective even if you become incapacitated, except as provided by Florida law.
Where can I obtain the Florida Health Care Surrogate form?
The form can typically be obtained from hospitals, healthcare providers, or legal offices. You can also find it online through various legal resources and state websites.
Filling out the Florida Health Care Surrogate form is an important task that requires careful attention. Many people make mistakes that can lead to confusion or even legal issues down the line. Here are five common errors to avoid when completing this form.
One frequent mistake is failing to specify an alternate health care surrogate. If the primary surrogate is unavailable or unwilling to act, it’s crucial to have a backup in place. Without this designation, there may be delays in decision-making during critical times. Always ensure that both the primary and alternate surrogates are clearly identified.
Another common error involves not providing complete contact information for the designated surrogate. Names alone are not enough. Include accurate phone numbers and addresses to facilitate communication when it matters most. Incomplete information can hinder the surrogate’s ability to act promptly and effectively.
Many individuals also overlook the importance of initialing the authorization sections. Each section requires initials to confirm that the surrogate has the authority to receive health information and make decisions. Failing to initial these areas can render the form invalid, leaving health care providers unsure about who can act on your behalf.
Additionally, some people neglect to discuss their wishes with their surrogates before completing the form. It’s essential that your surrogate understands your values and preferences regarding health care decisions. Without this conversation, the surrogate may make choices that do not align with your wishes, leading to potential conflicts during a health crisis.
Finally, forgetting to sign and date the form is a critical oversight. A signature is necessary to validate the document, and without it, the form holds no legal weight. Always double-check that you have signed and dated the form before submitting it or providing it to your health care providers.
The Florida Health Care Surrogate form is an essential document that allows individuals to designate someone to make health care decisions on their behalf if they become unable to do so. Alongside this form, there are several other documents that can be helpful in managing health care and end-of-life decisions. Below is a list of related forms and documents commonly used in conjunction with the Florida Health Care Surrogate form.
Having these documents in place can provide clarity and peace of mind for both the individual and their loved ones. It ensures that health care decisions align with personal values and preferences, particularly during critical moments when communication may not be possible.
The Florida Health Care Surrogate form shares similarities with several other important legal documents that address health care decisions and personal autonomy. Below is a list of these documents, highlighting how they are comparable to the Florida Health Care Surrogate form.
When filling out the Florida Health Care Surrogate form, it is important to follow certain guidelines to ensure that the document is valid and accurately reflects your wishes. Below is a list of things to do and avoid during this process.
Misconception 1: The Health Care Surrogate form only applies in cases of terminal illness.
This is incorrect. The Health Care Surrogate form is relevant whenever an individual is unable to make their own health care decisions, regardless of whether the condition is terminal. It is designed to ensure that someone can make decisions on behalf of the individual when they lack the capacity to do so.
Misconception 2: A Health Care Surrogate can make any decision without limitations.
This is not true. While a Health Care Surrogate has broad authority to make health care decisions, the individual can specify restrictions or instructions in the form. These preferences must be respected by the surrogate.
Misconception 3: Completing the form means the surrogate's authority is effective immediately.
The authority of the Health Care Surrogate only becomes effective when the primary physician determines that the individual is unable to make their own health care decisions, unless the individual chooses to have the authority activated immediately by initialing the appropriate box on the form.
Misconception 4: Once designated, a Health Care Surrogate cannot be changed or revoked.
This is false. An individual can revoke or amend the designation at any time while they retain decision-making capacity. This can be done through various means, including signing a new designation or verbally expressing the intent to change it.
Misconception 5: The Health Care Surrogate form is not legally binding.
In fact, the Health Care Surrogate form is legally binding under Florida law, provided it is executed in accordance with the requirements outlined in Chapter 765. It is crucial for individuals to understand that this document holds significant legal weight in health care decisions.
Filling out the Florida Health Care Surrogate form is an important step in ensuring your health care wishes are respected. Here are key takeaways to keep in mind:
Completing this form thoughtfully can provide peace of mind for you and your loved ones, ensuring that your health care preferences are honored when it matters most.