Edwin Peck
Health Care Surrogate
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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, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law, 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.  ________________________________

F.S. 765.202 (2006) Designation of a health care surrogate.—
(1)  A written document designating a surrogate to make health care decisions for a principal shall be signed by the principal in the presence of two subscribing adult witnesses. A principal unable to sign the instrument may, in the presence of witnesses, direct that another person sign the principal's name as required herein. An exact copy of the instrument shall be provided to the surrogate.
(2)  The person designated as surrogate shall not act as witness to the execution of the document designating the health care surrogate. At least one person who acts as a witness shall be neither the principal's spouse nor blood relative.
(3)  A document designating a health care surrogate may also designate an alternate surrogate provided the designation is explicit. The alternate surrogate may assume his or her duties as surrogate for the principal if the original surrogate is unwilling or unable to perform his or her duties. The principal's failure to designate an alternate surrogate shall not invalidate the designation.
(4)  If neither the designated surrogate nor the designated alternate surrogate is able or willing to make health care decisions on behalf of the principal and in accordance with the principal's instructions, the health care facility may seek the appointment of a proxy pursuant to part IV.
(5)  A principal may designate a separate surrogate to consent to mental health treatment in the event that the principal is determined by a court to be incompetent to consent to mental health treatment and a guardian advocate is appointed as provided under s. 394.4598. However, unless the document designating the health care surrogate expressly states otherwise, the court shall assume that the health care surrogate authorized to make health care decisions under this chapter is also the principal's choice to make decisions regarding mental health treatment.
(6)  Unless the document states a time of termination, the designation shall remain in effect until revoked by the principal.
(7)  A written designation of a health care surrogate executed pursuant to this section establishes a rebuttable presumption of clear and convincing evidence of the principal's designation of the surrogate.