The Florida Health Care Surrogate form is a legal document that allows you to designate someone to make health care decisions on your behalf if you become unable to do so. This form ensures that your health care preferences are respected and that a trusted individual can act in your best interest during critical times. It is important to understand the implications of this designation and to fill out the form accurately.
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The Florida Health Care Surrogate form serves as a vital tool for individuals seeking to ensure their medical preferences are honored when they are unable to communicate those wishes themselves. This legally binding document allows a person to designate a trusted individual as their health care surrogate, empowering them to make medical decisions on their behalf. The form outlines essential details, including the surrogate's name, contact information, and the appointment of an alternate surrogate in case the primary surrogate is unavailable. Importantly, it grants the surrogate the authority to access health information and make decisions regarding medical treatment, including life-prolonging procedures. Individuals can also specify any restrictions or specific instructions related to their health care. Notably, while the individual retains decision-making capacity, their wishes take precedence, emphasizing the importance of clear communication between the surrogate and the individual. This form remains effective even if the individual later becomes incapacitated, ensuring that their health care preferences are respected and upheld in critical situations.
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.
Completing the Florida Health Care Surrogate form is an important step in ensuring your health care preferences are respected. This form 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 fill out the form correctly.
Once you have completed the form, keep a copy for your records. It is advisable to share copies with your designated surrogate and your health care providers. This ensures that your wishes are known and can be acted upon when necessary.
The Florida Health Care Surrogate form is a legal document that allows an individual to designate another person to make health care decisions on their behalf if they become unable to do so. This form ensures that your medical preferences are honored, even when you cannot communicate them yourself.
Any competent adult can be designated as a health care surrogate. This person should be someone you trust to make medical decisions that align with your wishes. It is important to choose someone who understands your values and preferences regarding health care.
A health care surrogate has the authority to make a wide range of health care decisions, including:
The authority of your health care surrogate becomes effective only when your primary physician determines that you are unable to make your own health care decisions. However, you can choose to activate this authority immediately by initialing the appropriate box on the form.
Yes, you can revoke or amend your 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 existing form in a manner that shows your intent to revoke it.
Yes, you can include specific instructions and restrictions regarding your health care preferences. These should be clearly written in the designated section of the form. It is crucial that your surrogate understands these instructions to ensure your wishes are respected.
If your primary health care surrogate is not willing, able, or reasonably available to perform their duties, you can designate an alternate health care surrogate. This ensures that there is always someone available to make decisions on your behalf.
The health care surrogate designation does not expire automatically. It remains effective until you revoke it or until your death. However, it is advisable to review and update your designation periodically, especially after significant life changes.
If you provide any verbal or written instructions while you are still capable of making decisions, those instructions take precedence over any decisions made by your surrogate that conflict with your wishes. This ensures that your preferences are prioritized.
Yes, the form must be signed in the presence of two witnesses. These witnesses cannot be your health care surrogate or your immediate family members. Their signatures help verify that you were of sound mind when you completed the form.
Incomplete Information: Many individuals fail to provide all necessary details, such as the names, phone numbers, and addresses of both the primary and alternate health care surrogates. This omission can lead to confusion and delays in critical situations.
Not Initialing Required Sections: The form requires initials in specific sections to grant authority to the health care surrogate. Skipping these initials can result in the surrogate not having the necessary power to make decisions or access health information.
Failure to Update the Designation: Some people forget to amend or revoke the designation when their circumstances change, such as when a surrogate becomes unavailable or when they wish to appoint a different person. Keeping the document current is essential for ensuring that your wishes are respected.
Neglecting Witness Signatures: The form requires signatures from witnesses to validate the designation. Not having these signatures can render the document invalid, undermining the entire purpose of having a health care surrogate.
When considering the Florida Health Care Surrogate form, several other documents may be beneficial for ensuring that health care wishes are clearly communicated and respected. Below is a list of commonly used forms that complement the Health Care Surrogate designation.
Utilizing these documents alongside the Florida Health Care Surrogate form can provide clarity and peace of mind regarding health care decisions. It is essential to ensure that all forms are completed accurately and stored in an accessible location for future reference.
The Florida Health Care Surrogate form shares similarities with the Durable Power of Attorney (DPOA) document. Both documents allow an individual to designate someone to make decisions on their behalf. The DPOA specifically grants authority over financial and legal matters, while the Health Care Surrogate form focuses on health care decisions. Both documents can become effective immediately or upon the principal's incapacity, depending on how they are drafted. This flexibility ensures that the appointed individual can act when necessary.
Another similar document is the Living Will. A Living Will outlines an individual's preferences regarding medical treatment in situations where they are unable to communicate their wishes. Like the Health Care Surrogate form, it addresses end-of-life care and specific medical procedures. However, the Living Will does not appoint a surrogate to make decisions; instead, it provides direct instructions about treatment preferences. Both documents serve to ensure that a person's health care wishes are respected when they cannot voice them.
The Medical Power of Attorney (MPOA) is also comparable to the Health Care Surrogate form. The MPOA specifically designates an individual to make medical decisions for someone who is incapacitated. Similar to the Health Care Surrogate form, it can include broad authority over health care choices, including life-sustaining treatments. Both documents emphasize the importance of having a trusted individual make decisions aligned with the individual's values and preferences.
The Advance Directive is another document that overlaps with the Health Care Surrogate form. An Advance Directive encompasses both a Living Will and a Health Care Surrogate designation. It allows individuals to express their wishes regarding medical treatment and appoint someone to make decisions on their behalf. This comprehensive approach ensures that all aspects of health care preferences are documented, providing clarity for medical professionals and family members alike.
The Do Not Resuscitate (DNR) order is similar in that it communicates specific health care wishes, particularly regarding resuscitation efforts. While the Health Care Surrogate form allows a designated person to make decisions, a DNR directly instructs medical personnel not to perform CPR in the event of cardiac arrest. Both documents are critical for ensuring that a person's health care preferences are honored, particularly in emergency situations.
The Physician Orders for Life-Sustaining Treatment (POLST) form also parallels the Health Care Surrogate form. The POLST translates an individual’s wishes about life-sustaining treatment into actionable medical orders. It is often used for patients with serious health conditions. Like the Health Care Surrogate form, the POLST emphasizes the importance of clear communication about treatment preferences, ensuring that medical teams are aware of the patient’s desires.
Lastly, the Mental Health Advance Directive is similar in that it allows individuals to outline their preferences for mental health treatment. This document can specify who should make decisions if the individual is unable to do so due to a mental health crisis. Like the Health Care Surrogate form, it empowers individuals to take control of their treatment options and ensures that their wishes are respected in times of incapacity.
When filling out the Florida Health Care Surrogate form, keep these important tips in mind:
Misunderstandings surrounding the Florida Health Care Surrogate form can lead to confusion and unintended consequences. Here are six common misconceptions:
Understanding these misconceptions can empower individuals to make informed decisions about their health care and ensure their wishes are honored when they are unable to communicate them themselves.
Filling out and using the Florida Health Care Surrogate form is an important step in ensuring your health care preferences are respected. Here are key takeaways to keep in mind: