This Florida Medical Power of Attorney (the "Document") grants authority to the person designated as the Health Care Surrogate to make medical decisions for the Principal under the provisions of the Florida Health Care Advance Directives Act (Florida Statutes, Chapter 765). By completing this document, the Principal ensures that their health care preferences are respected even if they are unable to make decisions for themselves due to incapacity or medical condition.
Principal Information:
- Full Name: _____________________________
- Address: _______________________________
- City, State, Zip: ________________________
- Date of Birth: __________________________
- Social Security Number: __________________
Health Care Surrogate Information:
- Full Name: _____________________________
- Address: _______________________________
- City, State, Zip: ________________________
- Phone Number: __________________________
- Alternate Phone Number: _________________
This document gives the Health Care Surrogate broad powers to make health care decisions on behalf of the Principal, including but not limited to:
- Consenting or refusing consent to any medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Selecting or discharging health care providers and institutions.
- Approving or disapproving diagnostic tests, surgical procedures, and programs of medication.
- Deciding upon the Principal's admission to or discharge from a health care facility.
- Accessing the Principal’s medical records as permitted by law.
The Principal may also include specific limitations on the Health Care Surrogate's powers or specific preferences regarding medical treatment in the spaces provided below:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Effective Date and Duration:
This Florida Medical Power of Attorney becomes effective immediately upon the incapacity of the Principal, as determined by a physician, and remains in effect until the Principal's death, unless revoked by the Principal in writing.
Signature of Principal:
Date: _______________
Signature: ____________________________
Witnesses: (As required by Florida law, the Principal’s signing of this document must be witnessed by two adult witnesses, neither of whom may be the designated Health Care Surrogate.)
- Witness 1 Name: ___________________________
- Witness 1 Signature: ______________________
- Witness 1 Date: _______________
- Witness 2 Name: ___________________________
- Witness 2 Signature: ______________________
- Witness 2 Date: _______________
It is advisable to discuss the contents of this Florida Medical Power of Attorney with your chosen Health Care Surrogate to ensure they understand your wishes. Keep the original document in a secure but accessible place, and provide copies to your Health Care Surrogate, family members, and any relevant health care providers.
