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    4. florida designation of health care surrogate

    Florida Designation of Health Care Surrogate

    Instant Download - Only $9.99

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    Florida Designation of Health Care Surrogate

    [PRINT YOUR NAME]

    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:

    [PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR SURROGATE]

    Name: ...

    Address: ...

    ... Zip Code: _______

    Phone: ...

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

    [PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATIVE 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.

    [ADD PERSONAL INSTRUCTIONS (IF ANY)]

    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:

    [PRINT THE NAMES AND ADDRESSES OF THOSE WHO YOU WANT TO KEEP COPIES OF THIS DOCUMENT]

    Name: ...

    Address: ...

    Name: ...

    Address: ...

    [SIGN AND DATE THE DOCUMENT]

    Signed: ...

    Date: ...

    [TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES]

    Witness #1:

    Signed: ...

    Address: ...

    Witness #2:

    Signed: ...

    Address: ...

    Other Forms You May Need

    • Florida Statutory Living Will
    • Florida General Durable Power of Attorney for Property & Finances (Immediate)
    • Florida General Durable Power of Attorney for Property & Finances (Upon Disability)
    • HIPAA Authorization and Waiver

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
    • Accuracy guarantee
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