Health Care Surrogate Form Florida

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Living Wills Health Care Surrogates and Advanced Directives The forms included on the Florida Agency for Health Care Administration s Health Care Advance Directives Consumer Guide scroll down to find the downloadable forms have been approved by the Supreme Court of Florida Name. In the event 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 Street Address City ________________________________ State _______ Zip Phone

Health Care Surrogate Form FloridaPursuant 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:_____________________________________________________ 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