Sep 30, 2019 | Global Documents |
State Zip State Zip Suggested form of a Health Care Surrogate, Florida Statutes Section 765.203 Designation of Health Care Surrogate Name In the event 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: Name Street Address City Phone If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate: Name Street Address City 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; or apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility 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. Name: ________________________________________________________________________ Name: ________________________________________________________________________ Signed: ________________________________________________________________________ 1. Witnesses 2. At least one witness must not be a husband or wife or a blood relative of the principal.
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