Outline
The Florida Health Care Surrogate form is an essential legal document that allows individuals to designate a trusted person to make health care decisions on their behalf in the event they become unable to do so. This form requires the designation of a primary health care surrogate, along with an alternate in case the primary is unavailable or unwilling to serve. It outlines the authority granted to the surrogate, which includes accessing medical information, providing informed consent, and making decisions regarding medical treatment, including life-prolonging procedures. The form also allows for specific instructions and restrictions to be included, ensuring that the individual's wishes are respected. Importantly, the authority of the health care surrogate becomes effective only when a physician determines that the individual is unable to make their own health care decisions. Individuals retain the right to revoke or amend this designation while they have decision-making capacity, providing flexibility and control over their health care preferences. Understanding the implications of this form is crucial for anyone considering their health care options and the role of their surrogate.
Sample - Florida Health Care Surrogate Form
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
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.
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.
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.
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:
_________________ ______________________________ _______________________________
Date Signature Printed Name
_________________________________________________________________________________
Address
Signatures of Witnesses:
Witness:_________________________________ Witness:_________________________________
Printed Name: ____________________________ Printed Name: ____________________________
Address: ________________________________ Address: ________________________________
________________________________ _________________________________
Phone: _________________________________ Phone: ___________________________________
Form Information
| Fact Name | Details |
|---|---|
| Governing Law | This form is governed by Chapter 765 of the Florida Statutes. |
| Designation | Individuals can designate a health care surrogate to make medical decisions on their behalf. |
| Alternate Surrogate | An alternate health care surrogate can be named if the primary is unavailable. |
| Health Information Access | The surrogate is authorized to receive all health information related to the individual. |
| Decision-Making Authority | The surrogate has the authority to make informed consent decisions regarding health care. |
| Revocation | Individuals can revoke or amend their designation while retaining decision-making capacity. |
| Effective Date | The surrogate's authority becomes effective when a physician determines the individual is unable to make their own decisions. |
Detailed Guide for Filling Out Florida Health Care Surrogate
Filling out the Florida Health Care Surrogate form is a straightforward process. This document allows you to designate someone to make health care decisions on your behalf if you are unable to do so. To ensure that your wishes are clearly communicated, follow these steps carefully.
- Begin by writing your full name at the top of the form where indicated.
- Designate your primary health care surrogate by filling in their name, phone number, and address in the specified sections.
- If you wish to appoint an alternate health care surrogate, provide their name, phone number, and address in the designated area.
- In the instructions section, initial the blank spaces to authorize your health care surrogate to receive your health information.
- Initial the next blank space to grant your health care surrogate the authority to make health care decisions for you.
- If you have specific instructions or restrictions, write them clearly in the provided space.
- Sign and date the form at the bottom where indicated. Ensure that your signature matches your printed name.
- Two witnesses must sign the form. Provide their printed names and addresses in the appropriate sections.
- Finally, ensure that each witness includes their phone number next to their printed name.
After completing the form, keep it in a safe place and consider sharing copies with your health care surrogate and your primary physician. This will help ensure that your health care wishes are respected when the time comes.
Obtain Answers on Florida Health Care Surrogate
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What is the Florida Health Care Surrogate form?
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 designation ensures that someone the individual trusts will be responsible for making important medical choices in line with their wishes.
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Who can be a health care surrogate?
Any adult can serve as a health care surrogate, provided they are willing and able to take on this responsibility. It is important to choose someone who understands your values and preferences regarding medical treatment. This person can be a family member, a close friend, or anyone you trust.
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What authority does a health care surrogate have?
A health care surrogate has the authority to make a wide range of health care decisions, including:
- Giving informed consent for medical procedures.
- Refusing or withdrawing consent for treatments.
- Accessing medical records and health information.
- Applying for benefits to cover health care costs.
- Making decisions about anatomical gifts.
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Can I include specific instructions or restrictions in the form?
Yes, the Florida Health Care Surrogate form allows you to include specific instructions or restrictions regarding your health care. This can guide your surrogate in making decisions that align with your personal values and preferences.
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When does the authority of my health care surrogate take effect?
The authority of your health care surrogate typically becomes effective when your primary physician determines that you are unable to make your own health care decisions. However, you can choose to have their authority take effect immediately by initialing the appropriate box on the form.
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Can I revoke or amend the designation of my health care surrogate?
Yes, you can revoke or amend the 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 document in the presence of another person.
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What happens if I regain decision-making capacity?
If you regain the ability to make your own decisions, your wishes will take precedence over those of your health care surrogate. This means that any health care decisions you make while capable will override any conflicting decisions made by your surrogate.
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Do I need witnesses to sign the form?
Yes, the Florida Health Care Surrogate form requires the signatures of two witnesses. These witnesses must be adults who are not related to you and who will not benefit from your estate. Their signatures help validate the document and ensure it meets legal requirements.
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Is the Health Care Surrogate designation permanent?
No, the designation is not permanent. It remains in effect until you revoke it or until your health care surrogate is no longer able to serve. You can change your surrogate or the terms of your designation as your circumstances or preferences change.
Common mistakes
Filling out the Florida Health Care Surrogate form can be a straightforward process, but there are common mistakes that individuals often make. These errors can lead to complications when the time comes to implement the designated health care surrogate's authority. Understanding these pitfalls can help ensure that your wishes are honored.
One common mistake is failing to provide complete information about the health care surrogate. It's crucial to include the surrogate's full name, phone number, and address. Omitting any of this information can create confusion and may result in delays when urgent health care decisions need to be made. A health care surrogate should be someone who can be easily contacted and who understands your wishes.
Another frequent error involves not designating an alternate health care surrogate. Life is unpredictable, and your first choice may not always be available to make decisions on your behalf. By failing to name an alternate, you risk leaving your health care decisions in limbo, which can be distressing for both you and your loved ones.
Many people also neglect to initial the required sections that grant their health care surrogate specific powers. This step is not merely a formality; it indicates your consent for the surrogate to access your health information and make decisions regarding your care. Without these initials, the surrogate may not have the authority to act when needed.
Additionally, some individuals mistakenly believe that their health care surrogate's authority is automatically effective upon signing the form. However, the authority typically only becomes effective when a primary physician determines that the individual is unable to make their own health care decisions. Failing to understand this can lead to misunderstandings about when the surrogate can step in.
Another mistake is not communicating specific instructions or restrictions clearly. If there are particular wishes regarding medical treatment or interventions, they should be explicitly stated on the form. Vague instructions can lead to confusion and may not reflect your true desires when decisions need to be made.
People often overlook the importance of having witnesses sign the form. The signatures of two witnesses are generally required to validate the document. Without these signatures, the form may be deemed invalid, which can complicate matters when your health care surrogate needs to act on your behalf.
Finally, many individuals forget to keep a copy of the completed form in an accessible location. It’s essential to ensure that your health care surrogate and close family members know where to find it. If the form cannot be located when needed, it can create unnecessary stress during an already challenging time.
By being aware of these common mistakes, individuals can take proactive steps to ensure that their Florida Health Care Surrogate form accurately reflects their wishes and is legally valid. This careful attention to detail can provide peace of mind, knowing that your health care decisions will be honored when it matters most.
Documents used along the form
The Florida Health Care Surrogate form is an important document that allows individuals to designate someone to make health care decisions on their behalf if they become unable to do so. Along with this form, several other documents can complement or enhance its effectiveness. Here are a few commonly used forms:
- Living Will: This document outlines an individual's wishes regarding medical treatment and end-of-life care. It specifies what types of life-sustaining treatments should or should not be administered if the individual is unable to communicate their preferences.
- Durable Power of Attorney for Health Care: This form allows a person to appoint an agent to make health care decisions on their behalf. Unlike the health care surrogate, this document can grant broader powers, including financial decisions related to health care.
- Do Not Resuscitate (DNR) Order: A DNR order is a medical order that prevents health care providers from performing CPR if a person's heart stops or they stop breathing. It is crucial for individuals who do not wish to receive resuscitation in such circumstances.
- Anatomical Gift Form: This document allows individuals to specify their wishes regarding organ and tissue donation after death. It can be included in advance directives to ensure that a person's preferences are honored.
Each of these documents serves a unique purpose and can work together to ensure that an individual's health care preferences are respected. It's essential to consider these options carefully and discuss them with loved ones and health care providers.
Similar forms
- Durable Power of Attorney: This document allows someone to make financial and legal decisions on your behalf when you are unable to do so. Similar to the Health Care Surrogate form, it designates an individual to act in your best interest, but it focuses on financial matters rather than health care decisions.
- Living Will: A Living Will outlines your wishes regarding medical treatment in the event that you become incapacitated. Like the Health Care Surrogate form, it addresses end-of-life decisions but does so from your perspective rather than appointing someone to make those decisions for you.
- Do Not Resuscitate (DNR) Order: A DNR order specifies that you do not want to receive CPR or other life-saving measures if your heart stops or you stop breathing. This document is similar in that it communicates your health care preferences, but it is specifically focused on resuscitation efforts rather than appointing a surrogate.
- Advance Directive: An Advance Directive is a broader term that encompasses both the Health Care Surrogate form and Living Wills. It is a legal document that allows you to express your health care preferences and designate a surrogate to make decisions if you cannot. Both documents aim to ensure your wishes are respected.
- Anatomical Gift Declaration: This document allows you to specify your wishes regarding organ donation after death. It is similar to the Health Care Surrogate form in that it involves making decisions about your health and body, but it specifically addresses organ donation rather than health care decision-making during life.
Dos and Don'ts
When filling out the Florida Health Care Surrogate form, there are important dos and don'ts to keep in mind. This will help ensure that your wishes are respected and that the process goes smoothly.
- Do clearly identify your health care surrogate and alternate surrogate. Make sure their names, phone numbers, and addresses are accurate.
- Do read the entire form carefully before signing. Understanding each section is crucial to making informed decisions.
- Do initial all required spaces to indicate your consent for the surrogate to make health care decisions and receive your health information.
- Do discuss your wishes with your health care surrogate. Ensure they understand your preferences regarding medical treatment.
- Don't leave any blank spaces on the form. Incomplete forms can lead to confusion or disputes later.
- Don't forget to sign and date the form. Without your signature, the document is not valid.
Misconceptions
Understanding the Florida Health Care Surrogate form is crucial for anyone considering designating a surrogate for health care decisions. However, several misconceptions often arise. Here are ten common misunderstandings along with clarifications:
- Misconception 1: The Health Care Surrogate form is only for the elderly.
- Misconception 2: A health care surrogate can make any decision at any time.
- Misconception 3: The form is permanent and cannot be changed.
- Misconception 4: A health care surrogate can override the wishes of the individual.
- Misconception 5: You must hire a lawyer to complete the form.
- Misconception 6: Witnesses are not necessary for the form to be valid.
- Misconception 7: The surrogate must be a family member.
- Misconception 8: The health care surrogate can make financial decisions.
- Misconception 9: The form is only needed in case of terminal illness.
- Misconception 10: Once the form is signed, it cannot be discussed again.
This form is beneficial for anyone over the age of 18, regardless of health status. It allows individuals to designate someone they trust to make medical decisions on their behalf if they become incapacitated.
The authority of a health care surrogate only activates when the primary physician determines that the individual is unable to make their own health care decisions. Until that point, the individual retains full decision-making capacity.
Individuals can revoke or amend the designation at any time while they have decision-making capacity. This can be done through a written statement, destruction of the form, or verbal expression of intent.
The individual's wishes take precedence. If they have decision-making capacity, their instructions must be followed, even if they conflict with the surrogate's decisions.
The Florida Health Care Surrogate form can be completed without legal assistance. It is designed to be straightforward and accessible for all individuals.
Two witnesses are required to sign the form for it to be legally binding. These witnesses must be present when the individual signs the document.
While many people choose family members, the surrogate can be anyone the individual trusts, including friends or other trusted individuals, as long as they are over 18.
The surrogate's authority is limited to health care decisions only. They cannot make financial or legal decisions unless specifically authorized in a separate document.
The form is useful for any situation where an individual might become unable to make health care decisions, not just in terminal cases. This includes accidents or sudden illnesses.
It is advisable to discuss the designation with the chosen surrogate and family members. Open communication ensures everyone understands the individual's wishes and the surrogate's role.
Addressing these misconceptions can help individuals make informed decisions about their health care preferences and ensure their wishes are respected when they cannot advocate for themselves.
Key takeaways
Here are some key takeaways about filling out and using the Florida Health Care Surrogate form:
- Designate a Surrogate: You need to choose someone you trust to make health care decisions on your behalf. This person should be willing and able to take on this responsibility.
- Provide Clear Instructions: The form allows you to specify what decisions your surrogate can make. Make sure to initial the appropriate sections to indicate your preferences.
- Revocation is Possible: You can revoke or amend your designation at any time while you still have decision-making capacity. This can be done in writing, verbally, or by destroying the document.
- Authority Activation: Your surrogate’s authority to make decisions only takes effect when your primary physician determines you are unable to make your own health care decisions, unless you choose otherwise.