Fill and Sign the Health Care Proxy Designation of Health Care Surrogate Statutory Form Florida

DESIGNATION OF HEALTH CARE SURROGATE (Florida Statutes 765-203) 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 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: _____________________________________________________________________________ Signed: ______________________________________________________________________ Date: ______________________ Witnesses: 1. _____________________________________________________________________ 2. _____________________________________________________________________