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Overview

In the realm of safeguarding individual health care preferences, the Florida Health Care Surrogate form emerges as a critical legal tool. This document allows a person to designate another individual, known as a health care surrogate, to make decisions about their health care in the event they are unable to do so themselves. Provided within the structure of Florida Statutes, specifically under section 765.202, the form delineates the surrogate’s powers, ranging from accessing the designator’s health information to making all health care decisions, including consent for or refusal of treatment and even decisions about life-prolonging procedures. Moreover, the form addresses the surrogate's ability to apply for benefits on the designator’s behalf, painting a comprehensive picture of the surrogate's role. Importantly, while the form grants significant authority to the surrogate, it also emphasizes the designator's autonomy — stating that as long as they are capable, their own decisions and wishes are paramount, and must be clearly communicated to them by their caregivers. Adjustments or a complete revocation of the surrogate designation can be made at any time by the designator, provided they retain the capacity to do so, highlighting the flexibility and control retained by the individual creating the document. Hence, the Florida Health Care Surrogate form stands as a testament to the blend of trust and autonomy, enabling individuals to secure their health care preferences through thoughtful legal preparation.

Example - 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

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.

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 © 1995-2017 The Florida Legislature.

➤ Florida Health Care Surrogate PDF

File Specifications

Fact Detail
Governing Law Florida Statutes, Chapter 765
Form Purpose Designates a Health Care Surrogate
Primary Component Designation of a primary and an alternate Health Care Surrogate
Information Required Name, phone, and address of the designated surrogates
Health Care Surrogate's Powers Make health care decisions, apply for benefits, access health information, and make anatomical gifts
Initials Required For authorizing health information access and decision-making powers
Authority Conditions Becomes effective upon incapacitation or immediately if specified
Revocation and Amendment May be done any time with capacity through various methods like writing, destruction, verbal expression, or signing a new form
Witnesses Signature, printed name, and address of two witnesses

Instructions on Filling in Florida Health Care Surrogate

Filling out the Florida Health Care Surrogate form is a significant step towards ensuring that your health care preferences are honored, especially in circumstances where you might not be able to communicate your wishes yourself. This form allows you to designate someone as your health care surrogate, giving them the authority to make health care decisions on your behalf. It's important to approach this task thoughtfully, selecting someone who understands your values and whom you trust to act in your best interest. Here's how to complete the form:

  1. Start by printing your full name at the beginning of the form to identify yourself as the person making the designation.
  2. Designate your primary health care surrogate. Fill in their full name, phone number, and address in the designated area.
  3. Choose an alternate health care surrogate. In case your primary surrogate is unavailable or unable to make decisions, provide the name, phone number, and address of an alternate individual who can act as your surrogate.
  4. Initial the provided boxes to authorize your health care surrogate to receive your health information and to make health care decisions on your behalf. This includes decisions about your medical treatment and your personal health information.
  5. Provide any specific instructions or restrictions you wish to apply to the authority of your health care surrogate. If you have particular wishes about your health care, this section allows you to communicate them.
  6. Indicate whether the surrogate’s authority to receive health information and to make health care decisions becomes effective immediately or only upon a certain condition by initialing the appropriate box or boxes.
  7. Sign and date the form. Your signature is required to make this designation valid.
  8. Add the printed name, address, and phone number next to your signature for identification purposes.
  9. Have two witnesses sign the form. They must provide their names, addresses, and phone numbers. Note that the witnesses should not be the designated surrogate(s) to ensure impartiality.

Once completed, keep the document in a safe but accessible place and inform your designated surrogate(s) and your primary care physician of its existence and location. This will ensure that in the event of an emergency, your health care wishes are known and can be immediately acted upon.

Understanding Florida Health Care Surrogate

What is a Health Care Surrogate Form in Florida?

A health care surrogate form in Florida is a legal document that allows an individual to appoint another person, called a health care surrogate, to make health care decisions on their behalf when they are unable to do so. This can include decisions about medical treatments, accessing health records, and even making anatomical gifts. The form ensures that an individual's health care preferences are respected, even if they become incapacitated.

How does one appoint a Health Care Surrogate?

To appoint a health care surrogate in Florida, an individual must complete and sign a designation form. This form should include the name, phone number, and address of the chosen surrogate. If desired, an alternate surrogate can also be designated in the event that the primary surrogate is unable or unwilling to act. The form must be signed by the individual making the designation, and it is recommended, though not required by law, to have the signature witnessed or notarized to ensure validity.

Can I change my Health Care Surrogate?

Yes, individuals can change their health care surrogate at any time as long as they retain the capacity to make their own decisions. Changes can be made by completing a new designation form, destroying the original designation, expressing the intent to revoke the designation verbally, or by signing a written and dated document that specifies the intention to amend or revoke the existing designation. It's crucial to communicate any changes to the health care surrogate, alternate surrogate, and any relevant health care providers.

When does the authority of a Health Care Surrogate start?

The authority of a health care surrogate begins when a physician determines that the individual is unable to make their own health care decisions. However, the form allows individuals to grant immediate authority to the surrogate to receive health information or make health care decisions by initialing the appropriate box on the form. This flexibility ensures that the surrogate can act in the best interest of the individual, either immediately or at a future time when the individual is deemed incapable of making informed decisions.

Common mistakes

When filling out the Florida Health Care Surrogate form, people often make mistakes that can compromise the clarity and validity of the document. Understanding these common errors can help ensure the form serves its intended purpose effectively.

  1. Not providing complete information for the health care surrogate, such as full name, phone number, and address. This omission can lead to confusion or delays if the surrogate needs to be contacted.

  2. Failing to designate an alternate health care surrogate. Without an alternate, there's no clear direction on who should make health care decisions if the primary surrogate is unavailable.

  3. Forgetting to initial the sections where initials are required, including the authorization for the surrogate to receive health information and make health care decisions. Initials are necessary to confirm the choices explicitly.

  4. Omitting specific instructions and restrictions. This mistake can leave important decisions open to interpretation, which might not align with the person's wishes.

  5. Not discussing wishes with the designated surrogate. Communication ensures the surrogate understands their responsibilities and the person's preferences regarding health care treatment.

  6. Overlooking the need to update the form. Changes in relationships, contact information, or health care preferences necessitate updating the form to keep it relevant.

  7. Not properly revoking or amending the designation when changes are desired. The form outlines specific ways to revoke or amend the document, and failing to follow these can result in outdated or unwanted directives being followed.

  8. Incorrectly assuming the form's scope. Some people believe the form grants broader powers than it does, such as financial decision-making authority, which is not covered by this health care surrogate designation.

By avoiding these common mistakes, individuals can ensure their health care surrogate form is accurate, comprehensive, and reflective of their health care decision-making preferences.

Documents used along the form

When planning for healthcare decisions, especially in cases where one may not be able to make those decisions themselves, the Florida Health Care Surrogate form plays a vital role. Alongside this crucial document, there are several other forms and documents that individuals often consider to ensure their wishes are fully understood and respected. These tools provide an additional layer of clarity and assurance for both the individual and their loved ones.

  • Living Will: This document allows individuals to outline their preferences for medical treatment and life-sustaining measures in situations where they are no longer able to communicate their wishes due to incapacitation. It acts as a guide for healthcare providers and surrogates to follow.
  • Durable Power of Attorney for Healthcare: Similar to a Health Care Surrogate form but broader in scope, this legal document grants a designated person the authority to make all types of healthcare decisions on behalf of the individual if they become unable to do so themselves.
  • Do Not Resuscitate Order (DNRO): A DNRO is a doctor's order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the person's breathing stops or if the heart stops beating. It is intended for individuals in the final stages of terminal illnesses or with specific medical conditions.
  • Organ and Tissue Donation Registration: This registration allows individuals to express their wishes regarding organ and tissue donation upon their death. It can be specified on a driver’s license or through a state registry, and individuals may also wish to inform their health care surrogate of their decision.
  • Pre-Hospital Do Not Resuscitate Order: This is specifically designed for emergency medical services and indicates that resuscitation attempts should not be initiated if the individual experiences cardiac or respiratory arrest outside of a hospital setting. It is a separate document from the in-hospital DNRO and must be obtained and completed through specific processes.

Including these documents in one's healthcare planning ensures a comprehensive approach to managing one's health care decisions. While the Florida Health Care Surrogate form designates someone to make health care decisions on an individual's behalf, the accompanying documents further clarify one's wishes about life-sustaining treatment, organ donation, and other critical healthcare choices. Together, these forms provide a clearer picture of one’s healthcare preferences, offering peace of mind to both the individual and their designated surrogate.

Similar forms

The Florida Health Care Surrogate form shares similarities with various legal documents, each designed to ensure a person's wishes are respected, especially in times when they may not be able to communicate those wishes themselves. These documents span a range of personal, financial, and health-related areas, reflecting the breadth of considerations an individual might need to address in planning for the future.

  • Living Will: Just like the Florida Health Care Surrogate form, a living will specifies an individual's desires regarding medical treatment if they become incapacitated or unable to communicate their decisions. Both documents focus on healthcare decisions, but a living will typically outlines specific wishes for treatment in various scenarios, whereas a healthcare surrogate form designates someone to make those decisions.
  • Durable Power of Attorney for Health Care: This document, similar to the health care surrogate form, allows an individual to appoint someone to make health care decisions on their behalf if they're unable. The key similarity lies in the designation of an agent; however, the durable power of attorney may encompass decisions that are not strictly related to health care, depending on the jurisdiction and the specific terms of the document.
  • General Durable Power of Attorney: Like the health care surrogate form, this grants broad authority to an agent to act on the principal's behalf, covering financial and legal matters in addition to health care in some instances. Whereas the health care surrogate form is specifically for health decisions, a general durable power of attorney covers a wider scope of actions and decisions.
  • Do Not Resuscitate (DNR) Order: A DNR shares the health-focused intention of the health care surrogate form, particularly in emergency or critical care scenarios. Both documents influence the provision of care under specific circumstances, but a DNR expressly limits actions, directing providers not to perform CPR or other life-sustaining measures.
  • Advance Directive: This is a broad term that can include elements of both a living will and the designation of a health care surrogate. An advance directive ensures an individual's health care preferences are known and followed when they cannot speak for themselves, embodying the core purpose of the health care surrogate form by including instructions for care and the appointment of an agent.
  • Organ Donation Form: While the primary purpose of an organ donation form is to consent to the donation of organs posthumously, it intersects with the health care surrogate form through its inclusion in health care planning and decisions that may need to be made at the end of life or in critical care situations.
  • Guardianship Arrangement: Similar in its intention to protect the interests of the person, a guardianship arrangement can encompass decisions about health care, living arrangements, and personal care. Unlike a health care surrogate, which is specifically for health care decisions, guardianship can be more comprehensive, covering a wide range of personal and financial decisions.
  • HIPAA Authorization Form: This form allows for the sharing of an individual’s health information with designated parties, similar to how a health care surrogate may receive health information to make informed decisions. Although it doesn't delegate decision-making power, it facilitates the surrogate's ability to make decisions by ensuring access to necessary medical records.
  • Power of Attorney for Mental Health Care: Focused more specifically than a general health care surrogate form, this power of attorney addresses decisions regarding the treatment of mental health. It parallels the health care surrogate in anticipating scenarios where the individual cannot make decisions independently, ensuring that their mental health care preferences are respected and executed.

Dos and Don'ts

When filling out the Florida Health Care Surrogate form, it's essential to ensure all your wishes regarding health care decisions are properly documented. To guide you through the process, here are some things you should do and some pitfalls to avoid.

Do's:
  • Choose your surrogate carefully: Ensure the person you designate as your health care surrogate is someone you trust completely to make health care decisions on your behalf. They should be willing, available, and capable of performing their duties.
  • Include clear instructions: Use the section provided for specific instructions to detail any particular wishes you have about your health care. This can include preferences about life-prolonging procedures, pain management, or any other important health care decisions.
  • Discuss your wishes with your surrogate: It's crucial that your health care surrogate understands your preferences. Have an open and honest conversation with them about your values and what you consider quality of life.
  • Keep the form accessible: Once completed, inform your family members where the designation form is stored. Consider giving copies to your primary care physician and your designated health care surrogate.

Don'ts:
  • Leave blanks on the form: Ensure you fill out every section of the form, including providing initials where required. Incomplete forms may result in confusion or delay when your surrogate needs to act on your behalf.
  • Forget to update the form: Review and, if necessary, update your health care surrogate designation periodically. Changes in your health, personal beliefs, or relationships may warrant adjustments to your designation.
  • Fail to provide contact information: Make sure to include current and complete contact information for both your primary and alternate surrogates to ensure they can be reached quickly in an emergency.
  • Use unclear language: Avoid using vague or ambiguous terms in the specific instructions section. Be as clear and descriptive as possible to ensure your exact wishes are understood and followed.

Misconceptions

There are several common misconceptions about the Florida Health Care Surrogate form. Understanding these will help ensure that individuals make informed decisions regarding their health care planning.

  • Misconception 1: A health care surrogate designation is only for the elderly or those with serious health issues. Truth: Any adult can benefit from having a designated health care surrogate. Life is unpredictable, and having a surrogate can ensure someone is authorized to make health care decisions if you're unable to do so.

  • Misconception 2: Designating a health care surrogate means losing control over your medical decisions. Truth: You maintain control over your health care decisions as long as you are capable of making them. The surrogate only steps in if you're unable to make your own decisions.

  • Misconception 3: A health care surrogate has immediate authority once the form is signed. Truth: The surrogate's authority to make health care decisions only becomes active when your primary physician determines you are unable to make your own decisions, unless you specify otherwise on the form.

  • Misconception 4: Health care surrogate designations are irrevocable. Truth: You can revoke or amend your designation at any time as long as you have the capacity to do so.

  • Misconception 5: A health care surrogate can make decisions regarding the termination of life support regardless of the patient's condition. Truth: A surrogate is bound by your wishes as expressed in your health care surrogate designation or any other advance directive forms you may have completed.

  • Misconception 6: Your health care surrogate can override your existing advance directives. Truth: Any instructions you make, whether verbally or in writing, while you possess capacity, supersede any decisions made by your surrogate that conflict with your instructions.

  • Misconception 7: If you do not designate a health care surrogate, no one will be able to make health care decisions on your behalf. Truth: Without a designated surrogate, health care providers will turn to a legally recognized list of potential decision-makers, such as a spouse, adult children, or parents. However, designating a surrogate ensures the person you trust the most is making decisions for you.

  • Misconception 8: A legal professional must complete the health care surrogate form. Truth: While it's beneficial to seek professional advice, especially for complex situations, anyone can complete the form as long as it meets Florida’s legal requirements.

  • Misconception 9: The form is complicated and requires a lot of medical knowledge to complete. Truth: The form is designed to be straightforward. It primarily requires your personal information, the designation of your surrogate, and any specific instructions or restrictions you want to apply to your health care decisions.

Understanding these misconceptions is crucial for everyone. It helps clarify the purpose and function of the health care surrogate designation, ensuring that your health care wishes are honored, should you become unable to make those decisions yourself.

Key takeaways

When considering the completion and use of the Florida Health Care Surrogate form, several key takeaways emerge to guide individuals through the process effectively. Understanding these points can ensure your health care wishes are respected and can provide peace of mind for both you and your designated surrogate.

  • Designating a Health Care Surrogate is crucial: This form allows you to appoint someone to make health care decisions on your behalf should you become unable to do so. Ensure you choose a person who understands your health care preferences and whom you trust to act in your best interests.
  • Initials are required for authorization: Your initials are needed next to specific authorizations on the form. This includes allowing your surrogate to receive health information about you and make health care decisions for you. Initialing these sections confirms you understand and agree to these authorizations.
  • Providing clear instructions is essential: Though the form outlines general powers given to your surrogate, you have the option to include specific instructions or restrictions about the decisions they can make. This can guide them in making choices that align with your values and preferences.
  • Your wishes take precedence as long as you can communicate them: The form states that your health care surrogate's authority takes effect when your primary physician determines you cannot make health care decisions yourself. However, if you can express your wishes, they will override the surrogate's decisions. This reflects the importance of ongoing communication between you, your surrogate, and your health care providers.

Furthermore, the form is designed with mechanisms to amend or revoke the designation, underscoring the flexible nature of your health care planning. By signing and dating the document in the presence of witnesses, your designation becomes legally valid, offering a structured way to manage your future health care.

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