Florida designation of health care surrogate pdf

Florida designation of health care surrogate pdf

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Additional instructions (optional) Florida Designation of Health Care Surrogate Form. The person designated as Surrogate cannot act as condition; the provision of health care to me; or the past, present, or future payment for the provision of health care to me. I further authorize my health care surrogate to: (Initials required in the blank space below.) _____ Make all health care isions for me, which means he or she has the authority toProvide informed consent, refusal of consent, or health care isions 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): Produced for the Florida Developmental Disabilities Council By Program Design, Inc/03 I authorize my health care surrogate to: _____ (Initial Here) Receive health information whether oral or recorded in any form or medium, thatIs created or received by a health care provider, health care facility, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; AND 2 How do I designate a Health Care Surrogate? What is an I authorize my health care surrogate to: INSTRUCTIONS FOR HEALTH CARE duties, I designate as my alternate health care surrogate: If my health care surrogate is not willing, able, or reasonably availableto perform his or her Phone: _____ Name: _____ Statutes: I, _____, designate as my health care surrogate under s., Florida of health care to me; or the past, present, or future payment for the provision of health care to me. Apply on my behalf for private, public, fully understand that this designation will permit my designee to make health care isions and to provide, withhold, or withdraw consent on my behalf; or apply for public Living Wills, Health Care Surrogates, and Advanced Directives. ide to make an Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one The person present has a DESIGNATION OF HEALTH CARE SURROGATE FOR TREATMENT OF MINOR CHILD* in their name from the parent or guardian, How do I designate a Health Care Surrogate? Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care, including life-prolonging procedures. Which is best? What is an advance directive? I further authorize my health care surrogate to: Make all health care isions for me, which means he or she has the (initial here) authority toProvide informed consent, refusal of consent, or withdrawal of I fully understand that this designation will permit my designee to make health care isions and to provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility. A Florida designation of health care surrogate nominates a surrogate (trusted individual) to make medical isions for the person that completes the form (the principal). What is a health care surrogate designation? It is the official state form created by the Florida Bar and Florida Medical Association and referred to as a medical power Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. I fully understand that this designation will permit my designee to make health care isions and to provide, withhold, or withdraw consent on my behalf; to apply for public Designation of Health Care Surrogate. What is a living will? I authorize my health care surrogate to: (Initials required in blank spaces below.) Relates to my past, present, or future physical or Access my health information reasonably necessary for the health care surrogate to make isions involving my health care and to apply for benefits for me. The forms included on the Florida Agency for Health Care Administration’s Health Care Advance Directives Questions About Health Care Advance Directives.