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DESIGNATION OF HEALTH CARE SURROGATE
. DESIGNATION OF HEALTH CARE SURROGATE. 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:
| Surrogate Name: |
| Address: |
| , |
| Phone Number: |
| Relation, if any: |
. AUTHORITY OF SURROGATE. While I have decision-making 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.
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; to have access to my records necessary to make decisions or apply for benefits; and to authorize my admission to or transfer from a health care facility. I specifically give my Surrogate the authority to provide, withhold or withdraw consent to the provision of life-prolonging procedures on my behalf the provision of artificially provided nutrition and hydration. My Surrogate must act consistently with my desires as stated in this document or otherwise made known.
SECOND ALTERNATE SURROGATE
| Surrogate Name: |
| Address: |
| , |
| Phone Number: |
I affirm that this Designation is not being made as a condition of treatment or admission to a health care facility. I have read and understand the contents of this document and the effect of this grant of powers to my Surrogate. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Witness Signature: | ________________________________________ |
Date: ______________________________
| Witness Signature: | _________________________________________ |
Date: ______________________________
At least one witness is not 's spouse nor blood relative.
STATE OF ,
COUNTY OF , ss:
The foregoing instrument was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, ______ by , who is personally known to me or who has produced ________________________________ as identification.
_________________________________
Signature of person taking acknowledgment
_________________________________
Name typed, printed, or stamped
My commission expires _____________
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It's very easy to give or receive the authority you may need with a free Florida Medical Power of Attorney template from Rocket Lawyer:
This method, in many cases, would end up being notably less expensive and less time-consuming than hiring a conventional attorney. If needed, you can prepare this Medical PoA on behalf of your spouse or another relative, and then help them sign once you've drafted it. Please keep in mind that for a PoA form to be considered legally valid, the principal must be a mentally competent adult when they sign. In the event that the principal is already unable to make their own decisions, a conservatorship might be required. When facing this situation, it is best for you to talk to an attorney .
Anyone who is over 18 years old should have a Medical Power of Attorney. Though it is tough to acknowledge, a day might come when you are not able to make your own healthcare decisions. Here are some common occasions where you might find PoA forms to be helpful:
Regardless of whether your Florida Medical Power of Attorney is being drafted as part of a long-term plan or produced in response to an unexpected emergency, notarization and witnesses are strongly recommended for protecting your document if its credibility is doubted.
Sometimes, in discussing the subjects of estate planning or elder care with healthcare or legal professionals, you might hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used interchangeably. In short, they're the same. That being said, you should keep in mind that it's entirely possible to establish power of attorney over affairs that aren't health-related, in which case, "proxy" typically is not the preferred term.
Florida Medical PoA forms are generally straightforward, but you could have questions. The answer will depend on whom you ask, but sometimes a lawyer will not even agree to review your document if they were not the author. An easier approach to consider is to get help via attorney services at Rocket Lawyer. As a Premium member, you have the ability to ask for advice from an attorney with relevant experience or get answers to additional questions related to your Medical Power of Attorney. As always, Rocket Lawyer is here to help.
The cost of finding and working with a conventional lawyer to draft a Medical Power of Attorney could range anywhere from $200 to $500. When using Rocket Lawyer, you aren't just filling out a Power of Attorney template. In case you ever require support from a lawyer, your Rocket Lawyer membership offers up to 40% in savings when you hire an Rocket Lawyer network attorney.
Alongside your Power of Attorney, there's a set of tips for what is next after your document is completed. Feel free to engage with the PoA in all of the following ways: making edits, printing it out, and/or signing it. Finally, be sure that your agent(s) and care providers get their copy of the fully executed document.
The guidelines and restrictions vary in each state; however, in Florida, your document will need to be signed by two witnesses. Only one of your witnesses may be your spouse or another relative. Finally, as a basic standard, witnesses will need to be at least 18 years old, and none of them should simultaneously be your agent.
See Florida Medical/Healthcare Power of Attorney law: Chapter 765, Part II
