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The Florida Health Care Surrogate form is a crucial document that empowers an individual to appoint someone they trust to make health care decisions on their behalf when they can no longer speak for themselves. This form outlines critical components, including the designation of a primary health care surrogate and an alternate surrogate if the first choice is unavailable. It encompasses provisions that allow the surrogate to access the principal's health information, thus ensuring that important medical decisions can be informed and timely. Importantly, the form grants the surrogate the authority to consent to, refuse, or withdraw life-prolonging procedures and make decisions regarding the allocation of benefits for health care costs. Moreover, individuals can specify any instructions or restrictions to guide their surrogate's decision-making process. This document remains effective even if a person becomes incapacitated, emphasizing the need for individuals to be proactive in expressing their health care preferences. Additionally, while the surrogate's authority is triggered only when a physician determines an individual's incapacity, the form allows for immediate activation if the individual chooses. Ultimately, having a health care surrogate not only provides peace of mind but also assures that an individual's values and wishes are honored in critical moments when they may not be able to advocate for themselves.
Florida Health Care Surrogate Example
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:
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
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 ©
Form Characteristics
| Fact Title | Fact Description |
|---|---|
| Governing Law | The Florida Health Care Surrogate form is governed by Florida Statutes § 765.202 and § 765.203. |
| Designation Requirement | A written designation is not mandatory but is recommended for clarity on health care decisions. |
| Health Care Surrogate Authority | The health care surrogate has the authority to make all health care decisions when the individual is unable to do so. |
| Alternative Surrogate | Individuals can designate an alternate health care surrogate in case the primary surrogate is not available. |
| Information Access | The surrogate is authorized to receive any health information necessary for making informed decisions. |
| Informed Consent | Making informed consent or refusals regarding treatments is a key responsibility of the health care surrogate. |
| Revocation Process | A designation can be revoked at any time while retaining decision-making capacity through several specified methods. |
| Immediate Effect Option | Surrogates can begin to act immediately if the individual initials the appropriate box on the form. |
| Surrogate Decisions vs. Individual Wishes | Surrogate decisions made in conflict with the individual's express wishes are superseded if the individual has capacity. |
Guidelines on Utilizing Florida Health Care Surrogate
Completing the Florida Health Care Surrogate form is an important step in ensuring that your health care preferences are respected. It allows you to designate someone you trust to make healthcare decisions on your behalf if you become unable to do so. Following the steps below will help you fill out the form correctly.
- Begin by writing your full name at the top of the form.
- Designate your primary health care surrogate:
- Fill in the name of the person you choose as your health care surrogate.
- Include their phone number.
- Write down their address.
- If necessary, select an alternate health care surrogate by filling in the same details for another trusted person.
- Review the instructions for health care:
- Initial the blank spaces to authorize your surrogate to receive your health information.
- Initial again to grant your surrogate the authority to make health care decisions for you.
- Provide any specific instructions or restrictions you may have regarding your health care.
- Sign the form and date it where indicated.
- Have two witnesses sign the form, ensuring they print their names and addresses as required.
After completing the form, keep copies for your records and provide a copy to your designated surrogates. It’s also wise to discuss your health care wishes with them to ensure they understand your preferences. This proactive approach helps guarantee that your wishes are honored in times of need.
What You Should Know About This Form
What is the Florida Health Care Surrogate form?
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. By filling out this form, you grant your appointed surrogate the authority to make informed choices regarding your medical treatment and to access your health information. This ensures that your health care preferences are respected even when you can't communicate them yourself.
How do I choose my health care surrogate?
Selecting a health care surrogate is an important decision. Choose someone you trust, such as a family member or close friend, who understands your health care preferences. It’s imperative that this person is willing and able to take on the responsibility. Consider having conversations with your surrogate about your values and wishes regarding medical treatment. This dialogue will help ensure they can advocate for your interests effectively.
Can I change or revoke my health care surrogate designation?
Yes, you can change or revoke your health care surrogate designation at any time while you still have decision-making capacity. To do this, you can sign a new document expressing your intent, physically destroy the existing form, or verbally express your intention to amend or revoke it. Make sure to communicate any changes to your chosen surrogate and document them properly to avoid confusion later.
When does my health care surrogate's authority take effect?
Your health care surrogate's authority typically begins when your primary physician determines that you are unable to make your own health care decisions. However, you have the option to grant immediate authority for your surrogate to access your health information or make decisions by initialing specific boxes on the form. This flexibility allows you to tailor the document according to your preferences and needs.
Is there any limitation to the authority granted to my health care surrogate?
Common mistakes
When filling out the Florida Health Care Surrogate form, individuals often make several common mistakes that can impact the effectiveness of their designations. One such mistake is failing to provide complete contact information for the primary health care surrogate and any alternate. Leaving out critical details, such as phone numbers or addresses, can hinder communication during urgent situations when quick decisions are necessary. It is essential to ensure that all fields are fully filled out before submitting the form.
Another frequent error is neglecting to initial the required spaces that authorize the health care surrogate to receive health information and make decisions. These initials signify consent for the designated individual to act on one’s behalf. Without these initials, the authority granted to the surrogate may be unclear, leading to complications if decisions need to be made quickly. It is crucial to pay careful attention to these sections and provide the necessary initials.
People also often forget to include detailed specific instructions or restrictions regarding their health care preferences. The form provides space for individuals to outline any limitations or specific wishes concerning their medical treatment. Omitting this information may result in the surrogate making decisions that do not align with the individual's values or desires. Therefore, taking the time to articulate these instructions clearly can prevent misunderstandings in critical moments.
Lastly, some individuals may overlook the signature and witness requirements. The form must be signed and dated by the individual designating the surrogate, as well as witnessed appropriately. Failing to do so could render the form invalid. It is important to follow these procedural steps carefully to ensure that the designation holds legal weight and is actionable when needed.
Documents used along the form
When managing health care decisions, the Florida Health Care Surrogate form is essential. However, other documents often accompany it to ensure that your wishes are fully respected. Below is a list of commonly used forms. Each one plays a vital role in expressing your health care preferences and ensuring your loved ones are prepared to act on your behalf.
- Living Will: This document outlines your preferences regarding life-sustaining treatment in case you are unable to communicate. It specifies which medical interventions you want or do not want if you are near the end of life.
- Durable Power of Attorney for Health Care: This form allows you to appoint a trusted person to make health care decisions for you if you're unable to do so. It provides broader authority compared to a health care surrogate.
- Do Not Resuscitate (DNR) Order: A DNR order is a specific directive that prevents health care providers from performing CPR if your heart stops or you stop breathing. It’s crucial for those who wish to avoid invasive life-saving measures.
- Anatomical Gift Declaration: This document allows you to express your wishes about organ donation. You can designate specific organs or tissues to be donated after your death.
- Health Care Proxy Form: Similar to a health care surrogate form, this designates someone to make medical decisions on your behalf, but it may not cover as many areas as the surrogate form does.
- Medication Administration Record: This record provides details about your prescribed medications and aids health care providers in managing your treatment effectively while you are unable to communicate.
- Health Information Release Form: This document allows your health care surrogate or another designated person to access your medical records. It ensures they have the necessary information to make informed decisions on your behalf.
- Emergency Medical Services (EMS) Form: This form helps inform emergency responders about your health status and treatment preferences in case of an emergency. It can include any existing health care directives.
These documents can work together to create a comprehensive health care plan tailored to your wishes. Always discuss your choices with your family and health care providers, ensuring your preferences are understood and can be respected if the need arises.
Similar forms
- Durable Power of Attorney: Like the Florida Health Care Surrogate form, this document allows a person to appoint someone to make important decisions on their behalf. However, a Durable Power of Attorney can cover a broader range of decisions, including financial and legal matters, whereas the surrogate form is focused specifically on health care decisions.
- Living Will: A Living Will outlines specific medical treatments an individual wants or doesn’t want in the event they become unable to communicate their wishes. While both documents help guide health care decisions, the Living Will focuses more on end-of-life treatments, whereas the Health Care Surrogate form allows the designated surrogate more discretion in making decisions.
- Advance Directive: This term encompasses both the Health Care Surrogate form and Living Will. It refers to any document that gives guidance about an individual’s health care preferences in advance, especially regarding future incapacity.
- Do Not Resuscitate (DNR) Order: A DNR order indicates a person's wish not to receive CPR if their heart stops. While it’s specific about resuscitation, the Health Care Surrogate form provides a broader range of health decisions, permitting the surrogate to make choices based on an individual’s interests.
- Health Care Proxy: Similar to the Health Care Surrogate form, a Health Care Proxy designates someone to make health care decisions on someone’s behalf. It often serves the same function, with variations based on specific state laws and terminology.
- Do Not Intubate (DNI) Order: This order specifies that a person does not want to be intubated. Like a DNR, it provides specific instructions, whereas the Health Care Surrogate form allows for a broader decision-making scope by the appointed person.
- Post-Form Medical Orders: These orders, such as POLST (Physician Orders for Life-Sustaining Treatment), give specific medical orders based on a patient’s preferences. The Health Care Surrogate allows a surrogate to interpret the patient's wishes in a wider context of health care decisions.
- Medical Authorization Form: This form allows designated individuals to access a person's medical information. While it shares this authorization aspect, the Health Care Surrogate form includes additional authority to make decisions beyond just accessing information.
Dos and Don'ts
When filling out the Florida Health Care Surrogate form, it is important to follow specific guidelines to ensure that your wishes are clearly communicated and legally recognized. Here are eight dos and don'ts to consider:
- Do clearly identify your health care surrogate and alternate. Provide full names, phone numbers, and addresses.
- Do include specific instructions regarding your health care preferences if you have any.
- Do ensure you initial all required sections to authorize your surrogate's decisions and access to health information.
- Do make sure to sign and date the form in the designated area to validate it.
- Don't leave any sections blank that require your initials or signature. Incomplete forms can lead to confusion or legal issues.
- Don't designate more than one primary health care surrogate, as this can create conflicts in decision-making.
- Don't forget to have the form witnessed. Signatures of witnesses are essential for the form's validity.
- Don't assume that verbal instructions will be sufficient. Always document your preferences in writing for clarity and legal recognition.
Misconceptions
Understanding the Florida Health Care Surrogate form is essential for effective health care planning. However, several misconceptions can create confusion about its use and implications. Here are four common misconceptions:
- Once the form is signed, my surrogate can immediately make decisions for me. This is incorrect. The health care surrogate's authority only becomes effective when your primary physician determines that you are unable to make your own health care decisions, unless you choose to activate the authority immediately.
- I cannot change or revoke my designation once it’s completed. Many people believe that their choices are set in stone. However, as long as you have decision-making capacity, you can revoke or amend your health care surrogate designation at any time through a written, verbal, or physical action indicating your intent.
- My health care surrogate has unlimited power to make decisions on my behalf. This is misleading. While a health care surrogate has significant authority, they must still consider your wishes and keep you informed about decisions made on your behalf, especially while you retain capacity.
- The Health Care Surrogate form overrides my personal wishes. In truth, your preferences take precedence. Any health care decisions you make while possessing capacity supersede those made by your surrogate if there is a conflict.
Clarifying these misconceptions can ensure that individuals feel empowered in their health care decisions and that their wishes are respected during critical times.
Key takeaways
Filling out and utilizing the Florida Health Care Surrogate form is a significant step in ensuring your healthcare wishes are respected. Below are key takeaways that can aid in the process:
- Designate Your Surrogate: Clearly name your chosen health care surrogate and provide their contact information on the form.
- Alternate Surrogate: It is wise to designate an alternate health care surrogate in case your primary choice is unavailable.
- Understanding Authorization: By completing the form, you authorize your surrogate to access your health information and make critical health care decisions on your behalf.
- Initials Required: Ensure to initial the provided spaces to grant your surrogate specific powers, including making health care decisions and accessing your medical records.
- Communication of Wishes: While you retain decision-making capacity, your preferences take precedence. Medical providers must keep you informed about treatment options.
- Revocation of Designation: You can revoke or amend your designation at any time while you are still capable. This can be done through written notice, verbal expression, or by signing a new form.
- Effective Authority: Your surrogate’s authority becomes effective only when a physician determines that you can no longer make decisions about your health care.
- Immediate Effect Option: You have the option to allow your surrogate’s authority to take effect immediately by initialing that section of the form.
- Witness Requirements: Ensure that the form is signed in the presence of witnesses, which is crucial for its validity.
Taking the time to carefully complete this form can provide peace of mind and clarity about your healthcare wishes. Consider discussing your choices with your surrogate to ensure they fully understand your preferences.
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