Florida PDF Forms
Homepage ➾ Fill Out a Valid Florida Health Care Surrogate Template
Table of Contents

In the course of managing one's health care, particularly as it pertains to end-of-life decisions or circumstances in which an individual is unable to make decisions for themselves, the Florida Health Care Surrogate form emerges as a crucial legal instrument. This form enables individuals to designate another person, known as a health care surrogate, to make medical decisions on their behalf under the statutes outlined in section 765.202, Florida Statutes. The document requires not only the designation of a primary surrogate but also allows for the designation of an alternate surrogate, should the primary surrogate be unable or unwilling to perform their duties. It meticulously outlines the scope of the surrogate's authority, from accessing medical records to making decisions about the individual's medical treatment, including life-prolonging measures and the application for health care benefits. Interestingly, the form takes into account the retention of personal autonomy, clearly stipulating that the individual’s own decisions supersede those made by the surrogate as long as the individual is capable of making such decisions. Moreover, it addresses the conditions under which the surrogate's authority becomes effective, offering options for immediate effect or contingent upon a physician's determination of incapacity. Importantly, it also delineates the procedure for revoking or amending this designation. This form, therefore, not only serves as a vehicle for ensuring one's health care preferences are honored but also acts as a safeguard for personal autonomy, making it an essential component of health care planning in Florida.

Document Preview Example

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: ___________________________________

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.

Get PDF Form

Document Overview

Fact Detail
Purpose of the Form Designates a health care surrogate to make health care decisions on one's behalf should one become unable to do so.
Governing Law § 765.202, Florida Statutes, under Title XLIV, Chapter 765. Health Care Directives.
Authority Granted Includes receiving health information, making health care decisions, applying for benefits, and deciding on anatomical gifts.
Revocation and Amendment Can be revoked or amended at any time by a signed and dated instrument, destruction of the designation, verbally expressing intent, or signing a new, materially different designation.

Instructions on How to Fill Out Florida Health Care Surrogate

When planning for the future, it's crucial to make decisions about who will manage your health care should you become unable to do so. In Florida, the Health Care Surrogate form empowers someone you trust to make medical decisions on your behalf. Completing this form is straightforward, ensuring your health care wishes are respected even when you cannot express them yourself. Here's how to fill out the Florida Health Care Surrogate form step by step.

  1. Begin by writing your full name at the top of the form, thereby stating your intention to designate a health care surrogate under Section 765.202, Florida Statutes.
  2. Enter the full name, phone number, and address of the person you are designating as your health care surrogate.
  3. If desired, appoint an alternate health care surrogate by providing their name, phone number, and address. This step ensures there is someone to make decisions on your behalf if your primary surrogate is unable to fulfill their role.
  4. In the section labeled "INSTRUCTIONS FOR HEALTH CARE," initial the blank spaces to grant your health care surrogate specific powers. These powers include receiving your health information, making health care decisions including life-prolonging procedures, applying for benefits to defray health care costs, and making decisions about anatomical gifts.
  5. If you have specific instructions or restrictions for your health care surrogate, clearly describe these in the provided space. This ensures your health care preferences are followed.
  6. Note that your health care surrogate's decisions are secondary to yours as long as you are capable of making decisions. Ensure this is understood.
  7. Understand that this designation will remain in effect despite your incapacity unless amendments or revocations are made following the provided instructions in the form. These include written and dated instruments, physical destruction of the designation, verbal expressions of intent to revoke, or by signing a new, materially different designation.
  8. Decide if you want your health care surrogate's powers to take effect immediately or only upon your physician's determination that you cannot make health care decisions yourself. Initial the appropriate box(es) to reflect your choice.
  9. Sign and date the form at the designated area. Print your name and address below your signature.
  10. Have two witnesses sign the form, providing their printed names, addresses, and phone numbers. Their participation affirms your decision to designate a health care surrogate.

This form is a critical document in managing your future health care. It assures that your medical treatment aligns with your wishes, echoing your voice when you might not be able to speak. Upon completion, keep the form in a safe place and inform your surrogate, alternate surrogate, family members, and your health care provider of its existence and location. Taking this step now brings peace of mind, knowing your health care decisions are in trusted hands.

Listed Questions and Answers

What is a Florida Health Care Surrogate form?

A Florida Health Care Surrogate form is a legal document allowing an individual to designate another person (a surrogate) to make health care decisions on their behalf if they become unable to make these decisions themselves. This includes decisions about medical treatment and personal care.

Who can be designated as a health care surrogate in Florida?

In Florida, any competent adult can be designated as a health care surrogate. The chosen surrogate should be someone the principal trusts to make significant healthcare decisions for them. It's also possible to designate an alternate surrogate if the primary surrogate is not willing, able, or reasonably available to perform their duties.

What powers does a health care surrogate have?

A health care surrogate in Florida has the authority to receive health information about the principal, make health care decisions, provide informed consent, refuse or withdraw consent to treatment, apply for benefits on behalf of the principal, access the principal’s health information necessary for decision-making, and decide about anatomical gifts. These powers can be effective immediately or when the principal is determined to be unable to make their own health care decisions, depending on the initialing of specific boxes on the form.

How can someone activate the authority of a health care surrogate?

The authority of a health care surrogate becomes effective when the principal’s primary physician determines the principal is unable to make their own health care decisions. However, the form allows for the authority to receive health information and make health care decisions to become effective immediately if the principal initials the respective boxes.

Can instructions for health care be specified on the form?

Yes, the form provides a section where the principal can specify particular health care instructions and restrictions. This section allows the principal to outline any specific wishes or limitations they want the surrogate to follow when making health care decisions on their behalf.

Is the designation affected by the principal's incapacity?

No, the designation of a health care surrogate is not affected by the principal's subsequent incapacity unless otherwise specified in Chapter 765, Florida Statutes. The intent is to ensure continuous decision-making authority for the surrogate without the need for reassignment or confirmation post-incapacity.

How can the designation be revoked or amended?

A principal can revoke or amend the designation at any time, as long as they retain the capacity to do so. This can be done by signing a written and dated instrument expressing the intent to amend or revoke, physically destroying the designation, verbally expressing the intention to amend or revoke, or signing a new designation that is materially different from the current one.

What happens if there’s a conflict between the surrogate’s decisions and the principal’s wishes?

Any instructions or health care decisions made by the principal, either verbally or in writing, while they possess capacity, will supersede any decisions made by the surrogate that are in material conflict with those made by the principal. This ensures that the principal's wishes remain paramount.

How does one finalize a Florida Health Care Surrogate form?

The form must be signed and dated by the principal in the presence of two witnesses, who must also sign the document. These witnesses cannot be the designated surrogate or alternate surrogate. This formalizes the designation and confirms the principal's intent.

Common mistakes

  1. Not providing complete and clear information for the designated health care surrogate, including full name, phone number, and address. This information is crucial to ensure the surrogate can be contacted and identified without confusion when necessary.

  2. Failing to designate an alternate health care surrogate. Life is unpredictable, and the primary surrogate might not always be available. Having a backup is a sensible precaution to ensure decisions can be made without delay.

  3. Omitting the initials in the required spaces. This form includes sections where initials are necessary to authorize specific powers to the health care surrogate. Skipping these can lead to legal challenges or delay in health care decisions.

  4. Overlooking the importance of specifying instructions and restrictions for health care decisions. This part allows for personalized guidance on how to handle health care decisions, including limitations or specific wishes, which is essential for ensuring care aligns with personal values and preferences.

  5. Assuming the designation automatically grants immediate powers to the surrogate. The document clarifies that the surrogate's authority to make health care decisions becomes effective only upon the principal's incapacity unless otherwise indicated with an initial where specified.

  6. Ignoring the sections that allow for health information to be received and decisions to be made immediately upon designation if the principal desires by not initialing the appropriate box. This can be crucial, particularly in situations where immediate decisions may be necessary.

  7. Not properly executing the form with a date and signature. A dated signature from the individual making the designation is mandatory for the document to be legally valid and enforceable.

  8. Neglecting witness requirements. Florida law may require the health care surrogate designation to be witnessed by two individuals. Failure to comply with the witnessing requirements can invalidate the form.

  9. Forgetting to inform the designated surrogate and alternate surrogate about their appointment. It's imperative that the surrogates agree to their responsibilities ahead of time and understand the wishes of the person they are making decisions for.

These common mistakes can significantly impact the effectiveness and enforceability of the Florida Health Care Surrogate form. It is advised to review the form carefully, ensure all necessary information is accurately provided, and that all legal requirements are met. When in doubt, seeking professional guidance can help in avoiding these pitfalls.

Documents used along the form

When considering the Florida Health Care Surrogate form, it's pivotal to recognize that health care planning doesn’t stop there. There are several other forms and documents often used in conjunction with it that can offer a more comprehensive approach to managing one’s health and end-of-life care preferences. These documents work together to ensure that your health care wishes are understood and followed, providing peace of mind to both you and your loved ones.

  • Living Will: This document allows you to outline your preferences for medical treatment in case you become unable to communicate your decisions due to illness or incapacity. It often covers scenarios involving life-prolonging procedures.
  • Durable Power of Attorney: Separate from health care decisions, this document names someone to make financial decisions on your behalf if you’re unable to do so.
  • Do Not Resuscitate Order (DNRO): A DNRO is a medical order signed by a physician, indicating that you do not want to be revived if you stop breathing or your heart stops beating. This is particularly important for individuals with serious illnesses or those who are near the end of life.
  • Designation of Preneed Guardian: In the event you become unable to make decisions for yourself, this document specifies your preference for a guardian to handle your personal and financial matters.
  • Anatomical Donation Form: If you wish to donate your organs or body for transplantation or research, this form lets you outline your wishes clearly.
  • HIPAA Release Form: The Health Insurance Portability and Accountability Act (HIPAA) keeps your medical records private unless you consent otherwise. This form allows you to give permission for certain people to access your medical information.
  • Declaration for Mental Health Treatment: This document specifies your preferences for mental health treatment, including medications, counseling, and hospitalization, should you become unable to make these decisions yourself.

By having these additional documents in place, along with a Florida Health Care Surrogate form, you can ensure a comprehensive plan is ready for managing your health care and personal affairs in times of incapacity. Each document serves its unique purpose, contributing to a well-rounded approach to your personal and health care planning. It’s essential for individuals to consult with legal and health care professionals to fully understand each document and ensure they accurately reflect their wishes and legal requirements.

Similar forms

The Florida Health Care Surrogate form is similar to Living Wills and Durable Powers of Attorney for Health Care, among other legal documents. These documents serve crucial roles in managing a person's health care preferences and decision-making processes, especially during times when they cannot make decisions for themselves. While they share common goals, each form has distinct characteristics and serves slightly different purposes.

A Living Will, for instance, is a document that outlines an individual's preferences regarding the types of medical treatment they want to receive or avoid, particularly concerning end-of-life care. Similar to the Florida Health Care Surrogate form, a Living Will enables a person to express their health care wishes in advance. However, while the Health Care Surrogate form primarily designates another individual to make health care decisions on the person’s behalf, a Living Will focuses more on providing specific instructions about medical treatment based on various medical scenarios.

On the other hand, a Durable Power of Attorney for Health Care is a legal document that, like the Florida Health Care Surrogate form, allows an individual to appoint someone else to make health care decisions for them if they become incapable of making their decisions. The scope of this document can be broad or limited, giving the appointed person the authority to make a wide range of health care decisions or restricting them to specific actions. Unlike a Living Will, which is primarily directive, the Durable Power of Attorney for Health Care empowers someone else to make decisions, including those not specifically mentioned in the document, based on the incapacitated person’s best interests.

Dos and Don'ts

When filling out the Florida Health Care Surrogate form, it is crucial to adhere to guidelines that safeguard your interests and ensure your health care wishes are respected. Below is a list of do's and don'ts that should be considered during this process:

  • Do read the entire form carefully before beginning to fill it out to understand the responsibilities and powers you are granting to your surrogate.
  • Do choose a health care surrogate who you trust deeply; this should be someone who understands your health care preferences and is willing to act on your behalf.
  • Do provide clear and correct contact information for both your primary health care surrogate and your alternate, ensuring no errors that could delay critical decisions.
  • Do initial the specific powers you are granting to your surrogate carefully, considering what health information they can receive and the health care decisions they can make.
  • Do communicate your health care wishes to your surrogate, discussing your values and any specific medical treatments you do or do not want.
  • Do not leave spaces blank or assume certain instructions are implied; if you have specific wishes, such as limitations to the surrogate’s powers, clearly state these in the form.
  • Do not choose a health care surrogate without discussing the role with them first, ensuring they are willing and able to take on the responsibility.
  • Do not forget to sign and date the form in the presence of two witnesses, as failing to do so could invalidate the document.
  • Do not overlook the option to specify that the surrogate's powers to receive health information and make health care decisions become effective immediately, if this reflects your preferences.

Completing the Florida Health Care Surrogate form with diligence and foresight ensures that your health care decisions are in capable hands, reflective of your desires. Reviewing and updating the form as necessary keeps it aligned with your current wishes and circumstances.

Misconceptions

Understanding the Florida Health Care Surrogate form is crucial for effectively planning health care wishes. However, misconceptions can lead to confusion and improper use of this important document. Let's clarify some common misunderstandings.

  • It's only for the elderly or seriously ill: Many people believe that the health care surrogate form is only necessary for the elderly or those with serious health conditions. However, unexpected health care decisions can arise at any age, making it vital for every adult to consider having one.
  • It grants immediate power: A common misconception is that by designating a health care surrogate, individuals immediately relinquish their right to make their own health care decisions. In reality, the surrogate's authority to make decisions on behalf of the person typically becomes effective only when a physician determines that the individual is unable to make their own health care decisions, unless specified otherwise in the form.
  • It's the same as a living will: People often confuse a health care surrogate designation with a living will. While a living will specifies an individual's wishes regarding end-of-life care, a health care surrogate form designates another person to make health care decisions if the individual is unable to do so.
  • My family can always step in: Assuming that family members can automatically make health care decisions without a designated surrogate is mistaken. Without a health care surrogate form, family members may face legal barriers or disagreements about the best course of action.
  • A health care surrogate can override my wishes: Another misconception is that a health care surrogate has the power to override the individual's known wishes. The truth is, surrogates are expected to make decisions based on the person's known wishes and best interests. Additionally, individuals can provide specific instructions and restrictions in the form to guide the surrogate's decisions.
  • Any health care decision is final: People often worry that a decision made by a health care surrogate is final. However, the designation can be amended or revoked at any time by the individual as long as they possess the capacity to do so.
  • Designation is complicated and costly: The process of designating a health care surrogate is sometimes viewed as overly complicated and expensive, deterring individuals from completing it. In reality, Florida provides a suggested form that can be completed without legal assistance or significant expense.
  • It allows access to financial matters: There's a belief that a health care surrogate also has authority over an individual's finances. In fact, the surrogate's authority is strictly limited to making health care decisions, unless the designation specifically includes broader powers, which is generally not the case.
  • All family members need to agree on the designation: Lastly, while it's advisable to discuss the decision with family members, legally, the consent of the entire family is not required to designate a health care surrogate. The most important aspect is for the individual making the designation to trust the person they choose as their surrogate.

By debunking these misconceptions, individuals can make more informed decisions about the Florida Health Care Surrogate form, ensuring their health care wishes are respected and effectively communicated.

Key takeaways

When considering the designation of a Health Care Surrogate in Florida, it's essential to understand the specific roles, rights, and responsibilities involved. The Florida Health Care Surrogate form is a legal document that allows an individual to appoint someone else to make health care decisions on their behalf if they become unable to do so. Here are key takeaways to navigate this process effectively:

  • The designation of a Health Care Surrogate is supported by § 765.202 Florida Statutes, providing a legal framework for appointing a surrogate to make health care decisions on one's behalf.
  • It's crucial to carefully choose a trustworthy surrogate and an alternate who are willing and able to undertake this responsibility, ensuring they are reliable and readily available to act in your best interests.
  • Initials are required on the form to authorize the health care surrogate to receive health information and make health care decisions, signifying an explicit and deliberate action by the signatory to empower their surrogate with these capabilities.
  • Surrogate's health care decisions include providing informed consent, refusing or withdrawing consent to health care treatments, applying for benefits to defray health care costs, accessing necessary health information, and making anatomical gifts.
  • The form provides space for specific instructions and restrictions, allowing individuals to tailor the surrogate's authority to their wishes and moral beliefs regarding health care decisions.
  • Even after appointing a surrogate, the individual's wishes remain paramount while they retain decision-making capacity. Both health care providers and the surrogate are required to communicate with and consider the wishes of the individual.
  • The designation remains valid even if the person becomes incapacitated, but it can be revoked or amended at any time as long as the individual retains the capacity to do so through various methods, including a new written document or verbal expression.
  • The form indicates that the surrogate’s authority can take immediate effect for receiving health information or making health care decisions if the individual initials the respective boxes, offering flexibility in how and when the surrogate's powers are activated.
  • It's important to note that any written or verbal instructions made by the individual while they possess capacity will supersede decisions made by the surrogate that are in material conflict with those instructions, ensuring the individual's preferences are prioritized.

Completing and using the Florida Health Care Surrogate form involves thoughtful consideration, clear communication of wishes, and an understanding of the legal powers and limitations granted to the surrogate. Properly executed, it serves as a vital tool in health care planning, ensuring that health care decisions align with the individual's values and desires, even if they can no longer make those decisions themselves.

Please rate Fill Out a Valid Florida Health Care Surrogate Template Form
4.69
Excellent
180 Votes

Popular PDF Documents

Court Florida - Grasp the significance of completing the Notice of Hearing on Motion for Contempt/Enforcement to move your case forward in Florida.

What Is Form 1065 Used for - By calculating the net adjustment from other partnerships or joint ventures, the form addresses the interconnectedness of businesses for tax purposes.