October 18, 2019
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The Florida Statutes

The 2010 Florida Statutes(including Special Session A)

Title XLIV
CIVIL RIGHTS
Chapter 765
HEALTH CARE ADVANCE DIRECTIVES
View Entire Chapter
F.S. 765.203
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

Name:____(Last)____(First)____(Middle Initial)____

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:

Name:__________

Address:__________

________________________Zip Code:________

Phone:________________

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:

Name:__________

Address:__________

________________________Zip Code:________

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; to 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:__________

Date:__________

Witnesses:1.__________
 2.__________
History.s. 3, ch. 92-199; s. 1145, ch. 97-102; s. 9, ch. 2000-295; s. 1, ch. 2008-223.
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