Florida Advance Directive Form

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A Florida advance directive is a combination of forms used to outline an individual’s health care plans. Mainly, it allows a person to select an agent to act in their best interests in the chance they can no longer speak for themselves. Also, it outlines end-of-life medical requests and organ donation. Once signed, with at least two (2) witnesses, it may be used immediately.

Advance Directive Includes

Table of Contents

Laws

StatuteChapter 765 (Health Care Advance Directives)

Signing Requirements (§ 765.202(1), § 765.302(1)) – Two (2) witnesses.

State Definition (§ 765.101(1)) – “Advance directive” means a witnessed written document or oral statement in which instructions are given by a principal or in which the principal’s desires are expressed concerning any aspect of the principal’s health care or health information, and includes, but is not limited to, the designation of a health care surrogate, a living will, or an anatomical gift made pursuant to part V of this chapter.

Versions (5)


Cleveland Clinic

Download: Adobe PDF

 

 

 


FHCA Advance Directive

Download: Adobe PDF

 

 

 


FloridaHealthFinder.gov

Download: Adobe PDF

 

 

 


HealthFirst 

Download: Adobe PDF

 

 

 


NCH Healthcare

Download: Adobe PDF

 

 

 

How to Write

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Step 1 – Acquire The Florida Advance Directive From This Page

The  “PDF” button and “Adobe PDF” link on this page grant the same access to the Florida Advance Directive Use either of these items access the Florida Advance Directive available through this site.

Step 2 – Identify The Florida Principal Designating A Surrogate

The first document of the Florida Advance Directive enables you to designate the Health Care Surrogate who carries your approval to represent your medical treatment instructions to Florida Doctors seeking your approval or your refusal for treatment when you are incapacitated or in a vegetative state. The first line presented under the title “Health Care Surrogate Designation Form” requests your “Last,” “First,” and “Middle” name (in that order) as the Principal who seeks to appoint a Health Care Surrogate with such representational authority.

 

Step 3 – Produce A Formal Appointment Of The Florida Surrogate

The introduction of this paperwork will name the circumstances in which it will be appropriate for the Florida Health Care Surrogate to handle your medical decisions for you. Review the discussion provided in this brief paragraph. If you are in agreement with the introductory statement, continue to the blank line holding the “Name” label then dispense the full “Name” of the person being appointed to the Florida Health Care Surrogate role.  The “Address” line presented in this area seeks the residential address maintained by the Florida Health Care Surrogate.  Complete the process of formally identifying the Health Care Surrogate by recording his or her “Phone Number” where requested. 

 

Step 4 – Hold An Alternate Surrogate In Reserve

There may be circumstances in which your designated Florida Health Care Surrogate is “Unwilling Or Unable” to act in this role effectively. If this happens before you appoint another one, you will be left without the decision-making representation that a Health Care Surrogate can provide. You may prevent this scenario by identifying a person who will be able to step into this role and wield the same medical decision-making power by designating this ability to a specific person in the area following the statement “If My Surrogate Is Unwilling…” The “Name” line in this area shall seek the identity of the individual you have determined as your Alternate Surrogate. The second blank line of the Alternate Health Care Surrogate appointment seeks his or her full “Address” presented. Utilize the third line presented to document the Alternate Health Care Surrogate’s “Phone Number”

 

Step 5 – Put Your Specific Health Care Directive In Writing

While a designated Florida Health Care Surrogate and Alternate Surrogate have been named, it is generally recommended that some direct documentation of the Principal’s treatment preferences, aversions, and standpoints be put in writing. This should be done directly on the blank lines provided after the label “Additional Instructions (Optional).” If more room is needed to fully document your medical instructions, directions, or limitations to the Health Care Surrogate’s powers then compose your provisions on a separate document, attach it to this one, and dispense the title of the concerned attachments to these lines. This is not a mandatory item for this paperwork to be executed, so you may populate the “Additional Instructions” area with the word “None” if appropriate. 

 

Step 6 – Indicate Where You Will Dispense This Appointment Form

For this form to be effective in its goal of informing Florida Physicians that they must consult with your Health care Surrogate when you are unable to communicate, it must be dispensed to the Medical Facilities where you receive (or are most likely) to receive medical treatment during such a scenario or to a trusted family member. Furthermore, the identity of the Keepers of this document must be named after the paragraph ending with the term “…Copy Of This Document To The Following Persons Other Than My Surrogate So They May Know who My Surrogate Is” Use the first “Name” line following these words to identify the first Recipient.  The “Address” line that follows the first Recipient’s “Name” requires a report on his or her address. The third line here calls for the “Name” of the second Recipient who will store this document. Lastly, dispense the second Recipient’s “Address” to the next line.

 

Step 7 – Present The Florida Principal’s Executing Signature

This paperwork must be signed by the Principal in order for it to be recognized as a valid representation of your wishes. Thus, as the Principal, sign the blank line labeled “Signed” presented with the “Date” line to its right. In addition to signing this paperwork, you must also produce the “Date” when you signed this paperwork. Once you have completed this action, give this document to the Witnesses observing your actions.

 

Step 8 – Display Proof Of Authenticity For The Concerned Signature

The blank lines labeled “Witness 1” and “Witness 2” seek the signature of each Witness viewing your execution of this appointment.

 

Step 9 – Obtain The Florida Surrogate’s Formal Acceptance

The Health Care Surrogate you have designated above must be informed of his or her role. To this end, locate the “Acceptance Of Surrogate Designation” section then furnish the first blank line with the Florida Health Care Surrogate’s full name. Do not enter the name of the Alternate Surrogate. Continue through this statement to the space following the phrase “…To Act As Health Care Surrogate For” then furnish your full name to this line. After reading the above statement (after is completed), the Florida Health Care Surrogate must fill in his or her “Current Address” where requested before signing this acknowledgment statement. Lastly, the Florida Health Care Surrogate must deliver his or her signature to the blank line “Signed” then enter the current “Date” on the next line.  

 

Step 10 – Date The Florida Living Will Being Issued

As mentioned earlier, this paperwork includes a “Living Will” which may be found on the second page. To begin this process, seek the first three lines after the term “Declaration Made this…” then distribute the two-digit calendar day, the month and the two-digit year across the first three lines then your own name on the empty line preceding the language “…Willfully And Voluntarily Make Known…”   

 

Step 11 – Establish Declarant’s Purpose For The Living Will

This document can potentially be applied to three medical scenarios. To determine which scenarios, three checkboxes are presented in the middle of the first paragraph after the words “…If At Any Time I Am Incapacitated And..” You must initial each one you wish this document applied to. Therefore, if you wish to enact your living will when you are diagnosed with a “Terminal Condition” then initial the first checkbox.  If you wish your living will to determine how Florida Medical Personnel should proceed when you are incapacitated, then select the “I Have An End Stage Condition.” You may set this document as instructions to Medical Personnel when you are in a coma then initial the “I Am In A Persistent Vegetative State.” 

 

Step 12 – Name The Florida Surrogate Set To Safeguard The Declarant’s Wishes

You can specifically name your Florida Health Care Surrogate to safeguard your medical preferences in this matter so that he or she has the principal authority to enforce your living will if necessary. Record the full “Name” of the Florida Health Care Surrogate you are charging with this responsibility on the “Name” line placed below the words “…To Carry Out The Provisions Of This Declaration. This is not a necessary action, but strongly encouraged.  Furnish the “Address” line displayed in this area with the current building number, street or road name/number, and apartment number of his or her residence.  The “City,” “State,” and “Zip” lines are reserved to present the remainder of the Florida Health Care Surrogate’s address. Finish naming your Health Care Surrogate to this task by entering his or her contact telephone number on the line labeled “Phone.”  

 

Step 13 – Furnish Additional Instructions For Your Living Will

There may be certain medical conditions or scenarios in which a living will would normally be applied. If there are any you would feel are unwarranted or if you have additional concerns you wish addressed when in a vegetative state (i.e. you may wish to abstain from specific medications during a religious holiday) then report them in the space labeled “Additional Instructions…” You may also use this space to cite a title with such instructions, or if no other discussion is necessary, supply the word “None” to its content.  

 

Step 14 – Execute The Living Will As The Florida Declarant

The final line of this document shall seek the signature of its Declarant. Thus, provide your signature to the space labeled “Signed.” This action should be completed before two Witnesses. Once you have dispensed your signature, release this paperwork to these Parties. Each Witness must tend to only one of the signature areas provided next. The first line in the two columns presented expect the signature of one “Witness” to be presented for display. Next, both Witnesses must document their residential address on the two blank lines underneath his or her signature.  The final requirement each Witness must satisfy is to disclose his or her “Phone” number on the last line. 

 

Step 15 – Display The Issuer Of The Do Not Resuscitate Order

If you wish to include a “State Of Florida Do Not Resuscitate Order” in your advanced directive, then continue to the next page. Where your full name should be furnished to the “Patient’s Full Legal Name” line along with the “Date” you are issuing this document on the empty line that follows. 

 

Step 16 – Document The Party Who Will Execute The Florida DNR

While it is assumed that you are the Declarant issuing the DNR, this is not always the case. The Patient’s statement will need to be made by the Patient named above (Your) or someone with the legal authority to make it on your behalf. If this document is being completed by the Patient’s “Surrogate” or “Proxy” then select the appropriate box to indicate this by populating it with either a checkmark or an “X.” In the example below the “Surrogate” will issue this paperwork.  If a “Court Appointed Guardian” is issuing this paperwork on your behalf or these instructions are the result of a “Durable Power Of Attorney” then mark the appropriate checkbox on the next line. Notice in the example below, this paperwork is the result of the “Durable Power Of Attorney”  

 

Step 17 – Properly Execute The DNR If Desired

The blank line labeled “Applicable Signature” and “Print Or Type Name” must be signed by this paperwork Declarant or Issuer while the area on the right will require this Party to present his or her printed name above the “Print Or Type Name” label. 

 

Step 18 – Gain Proof Of the Florida Physician’s Directions

The Florida DNR must be approved by a Physician in a provable manner therefore he or she must review the “Physician’s Statement” then agree to it by signing his or her name on the “Signature Of Physician” area of the blank line provided below. This line also contains a segment where the Physician’s signature “Date” should be documented along with the digits making up the emergency telephone number where he or she can be reached.  Lastly, the Physician must print or type his or her name then produce his or her “Physician’s Medical License Number” on the areas where this is requested.

 

Step 19 – Solidify The Florida Patient’s Organ Donor Status

If (and only if) you wish to donate your organs or make anatomical gifts, locate the final page, titled Official Florida Organ Donation Registration Form, then record your Flordia State Driver’s License Number on the first available line on the left. You may indicate that you wish to donate any organ as needed by marking the box labeled “A,” that you will only donate certain organs “For The Purpose Of Transplantation, Therapy, Medical Research Or Education” by selecting the “B” checkbox then listing these organs on the line provided, strictly for the purpose of anatomical study by selecting the “C” box. Notice in the example provided, the default of “A Any Organ…” has been selected.  Continue one line down then furnish your “Social Security #” where it is requested. Notice the area on the right will seek a definition to the level of anatomical gift you wish to make. This report should be produced on the left side. When you turn your attention to the right the statement “Limitations Or Special Wishes, If Any, Listed Below” provides a blank line for your use should you wish to apply restrictions on your anatomical gifts such as organs may be donated for which purpose.   While your previous entries are an excellent measure of identification in the State of Florida, some additional information will be necessary for this purpose. The third and fourth requests made by this form is for your “Date Of Birth” and an indication of your “Sex.” This document requires that you report your birthday as a two-digit calendar month, two-digit calendar day, and the four-digit year before identifying your sex by placing an “X” on the line “M” for male or “F” for female.  Next, use the blank line labeled “Name” on the left, to identify yourself as the Organ Donor then the blank “Name” line on the right to record the identity of your “Nearest Relative.”Continue down these columns to document your residential address on the blank lines designated with “Address,” “City,” “State,” and “Zip” then, on the right use similarly labeled lines to furnish your Nearest Relative’s home address along with his or her home “Telephone” number. Sign this form before a Witness. Use the “Signature Of Donor” line on the left to provide your signature and the line below it to establish the “Date Signed,” then allow the Witness to sign the first line of the “Witness Information” section on the right and furnish the “Date Signed” below it.  The “Witness (Parent Or Guradian If Under 18)” line provided on the right in the “Witness Information” section has been made available as a convenience. If the Donor is under 18, generally referred to as a “Minor,” then one of the Minor’s parents must view this act then sign the concerned area. Once this task is complete he or she must produce the signature date.

 

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