Skip to Navigation | Skip to Main Content | Skip to Site Map

MyFloridaHouse.gov | Mobile Site

Senate Tracker: Sign Up | Login

The Florida Senate

2012 Florida Statutes

Title XLIV CIVIL RIGHTS
Chapter 765 HEALTH CARE ADVANCE DIRECTIVES Entire Chapter
SECTION 203
Suggested form of designation.
F.S. 765.203
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 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; s. 1, ch. 2008-223.