Title XLIV CIVIL RIGHTS

Chapter 765 HEALTH CARE ADVANCE DIRECTIVES

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, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law, 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.

Last modified: November 21, 2006

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Florida Civil Rights Code Section 765.203 - Health Care Advance Directives - Suggested form of designation.

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Title XLIV CIVIL RIGHTS

Chapter 765 HEALTH CARE ADVANCE DIRECTIVES