The Florida Health Care Surrogate form is a legal document that allows individuals to designate someone to make health care decisions on their behalf if they become unable to do so. This form ensures that your medical preferences are honored and that someone you trust can act in your best interest during critical times. To safeguard your health care wishes, consider filling out the form by clicking the button below.
In the realm of health care, ensuring that your wishes are respected when you can no longer communicate them is vital. The Florida Health Care Surrogate form plays a crucial role in this process. This document allows individuals to designate a trusted person, known as a health care surrogate, to make medical decisions on their behalf if they become incapacitated. It provides space to name an alternate surrogate, ensuring that someone will always be available to advocate for your health care preferences. The form also outlines specific instructions regarding the authority granted to the surrogate, including the ability to access health information and make decisions about treatments, including life-prolonging procedures. Importantly, it emphasizes that while you retain decision-making capacity, your wishes take precedence. Moreover, you have the power to revoke or amend this designation at any time, ensuring that your rights and preferences remain central to your health care experience. Understanding this form is an essential step in preparing for the unexpected, allowing you to approach health care decisions with confidence and peace of mind.
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 is a straightforward process that allows you to designate someone to make health care decisions on your behalf if you are unable to do so. Follow these steps carefully to ensure that your wishes are clearly communicated.
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 if they become unable to do so. This form ensures that your health care preferences are respected, even when you cannot communicate them yourself. It outlines the authority given to the surrogate and can include specific instructions regarding your medical treatment.
Who can be designated as a health care surrogate?
Any competent adult can serve as a health care surrogate. This means that you can choose a family member, friend, or trusted individual who understands your values and wishes regarding medical treatment. It's important to select someone who is willing and able to take on this responsibility, as they will be making significant decisions about your health care.
How does the surrogate's authority work?
The authority of the health care surrogate becomes effective 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. This flexibility allows you to tailor the document to your needs and preferences.
Can I revoke or change my health care surrogate designation?
Yes, you can revoke or amend your health care surrogate designation at any time while you still have decision-making capacity. This can be done by signing a new document, verbally expressing your intent, or physically destroying the original form. It’s crucial to communicate any changes clearly to ensure that your current wishes are followed.
What happens if I do not designate a health care surrogate?
If you do not designate a health care surrogate, decisions about your health care may be made by family members or legal representatives according to Florida law. This could lead to disagreements or decisions that do not reflect your wishes. Having a designated surrogate helps prevent confusion and ensures that your preferences are honored during critical times.
Completing the Florida Health Care Surrogate form is an important step in ensuring that your medical decisions are made according to your wishes when you are unable to do so. However, many individuals make mistakes during this process that can lead to confusion or complications. Here are nine common errors to avoid.
One frequent mistake is leaving the name and contact information of the surrogate blank. This can create uncertainty about who is authorized to make decisions on your behalf. It is crucial to provide complete and accurate information for your designated surrogate, including their full name, phone number, and address.
Another common error involves failing to designate an alternate health care surrogate. In the event that your primary surrogate is unavailable, having an alternate can prevent delays in critical medical decisions. Be sure to fill out this section completely, just as you would for your primary surrogate.
Many people neglect to provide initials for the specific authorizations outlined in the form. Each section that requires your initials serves to confirm your understanding and consent regarding the powers you are granting your surrogate. Omitting these initials can render the document incomplete and may lead to questions about your intentions.
Additionally, failing to include specific instructions or restrictions can lead to misunderstandings. If you have particular wishes regarding your health care, it is essential to document them clearly. This ensures that your surrogate understands your preferences and can act accordingly.
Some individuals mistakenly believe that the form is effective immediately without understanding the implications of their choices. It is vital to indicate when your surrogate’s authority begins by initialing the appropriate boxes. If you want your surrogate to have immediate access to your health information or decision-making power, you must clearly indicate this.
Another error is neglecting to sign and date the form properly. The signature is a critical element that verifies your intent. Without it, the document may be considered invalid. Ensure that your signature is clear and that the date is current.
Witness signatures are also a key component of the form. Failing to have two witnesses sign can invalidate your designation. Make sure that the witnesses are present when you sign the document and that they also provide their printed names and addresses.
People often overlook the importance of keeping the document accessible. After completing the form, store it in a safe yet accessible location. Inform your surrogate and family members where it can be found to avoid delays in critical situations.
Finally, many forget to review the form periodically. Life circumstances change, and so might your wishes regarding health care decisions. Regularly revisiting and updating your designation can ensure that it continues to reflect your current preferences.
By avoiding these common mistakes, you can ensure that your Florida Health Care Surrogate form accurately represents your wishes and provides clear guidance to your surrogate when it matters most.
When considering the Florida Health Care Surrogate form, it is important to understand that it often accompanies other essential documents that help outline a person's health care preferences and legal designations. Each of these documents serves a unique purpose, ensuring that an individual's wishes are respected and followed in medical situations. Below are four commonly used forms that complement the Health Care Surrogate designation.
By understanding these documents, individuals can better prepare for future health care decisions. Ensuring that these forms are in place can provide peace of mind, knowing that personal wishes will be honored and respected in times of medical need.
Do's:
Don'ts:
Understanding the Florida Health Care Surrogate form is crucial for making informed decisions about your health care. Here are seven common misconceptions:
Clarifying these misconceptions can empower you to make better choices regarding your health care planning.
Filling out the Florida Health Care Surrogate form is an important step in ensuring your medical wishes are respected when you cannot speak for yourself. Here are some key takeaways to keep in mind:
Taking the time to fill out this form thoughtfully can provide peace of mind for you and your loved ones. It ensures that your health care preferences are honored, even when you cannot voice them yourself.