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Florida Designation Of Health Care Surrogate Templates Free Download
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Florida Designation of Health Care Surrogate [PRINT YOUR NAME] Name: ________________________________(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 procedures, I wish to designate as my surrogate for health care decisions: [PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR SURROGATE] Name: ... Address: ... ... Zip Code: _______ Phone: ... If my surrogate is unwilling or unable to perform his duties, I wish to designate as my alternate surrogate: [PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATIVE SURROGATE] Name: ... Address: ... ... Zip Code: _______ Phone: ... 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. [ADD PERSONAL INSTRUCTIONS (IF ANY)] Additional instructions (optional): I further affirm that this designation is not being made as a 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: [PRINT THE NAMES AND ADDRESSES OF THOSE WHO YOU WANT TO KEEP COPIES OF THIS DOCUMENT] Name: ... Address: ... Name: ... Address: ... [SIGN AND DATE THE DOCUMENT] Signed: ... Date: ... [TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES] Witness #1: Signed: ... Address: ... Witness #2: Signed: ... Address: ... Other Forms You May Need * Florida Living Will * Florida General Durable Power of Attorney for Property & Finances (Immediate) * Florida General Durable Power of Attorney for Property & Finances (Upon Disability) * HIPAA Authorization and Waiverclick to download Florida Designation Of Health Care Surrogate template
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