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

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FloridaHealthFinder.gov

Download: Adobe PDF

 

 

 


HealthFirst 

Download: Adobe PDF

 

 

 


NCH Healthcare

Download: Adobe PDF

 

 

 

How to Write

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Florida Health Care Principal

(1) Name. This package shall contain several documents to allow for multiple Patient directives to be issued by a Florida Principal or Declarant seeking to inform Physicians in this state of his or her medical needs in case a medical condition causes severe incapacitation or leaves the Florida Principal unable to communicate. Produce the full name of the Florida Principal who wishes to set medical treatment instructions for the benefit of attending Physicians in this state.

Health Care Surrogate

(2) Health Care Surrogate Identity. Several precautions can be set by the Florida Principal using this paperwork. The first of which is to name a Health Care Surrogate. This Party will communicate with Florida Medical Providers regarding the Principal’s treatment choices should the Principal be rendered unable to communicate at a time when procedures to treat a serious medical event or condition require determination, consent, refusal, or consultation with the Patient. The full name of the Florida Principal’s first choice for Health Care Surrogate should be presented in this role. Naturally, his or her contact information will also be necessary.

(3) Health Care Surrogate Address.

(4) Health Care Surrogate Phone Number.

Alternate Surrogate

(5) Alternate Surrogate Name. The Florida Health Care Surrogate should be someone reliable that the Principal trusts and keeps informed of his or her medical preferences and decisions at all times however, there may be circumstances that prevent the Health Care Surrogate from effectively acting for the Principal or from wielding the authority to make medical decisions on his or her behalf. The Florida Principal can still make sure he or she has a continuous voice in his or her treatment options when unable to communicate by listing an Alternate Surrogate Agent who can, using this paperwork, assume principal authority and discuss the Principal’s treatment with Florida Physicians. To name a Florida Alternate Health Care Surrogate, his or her full name and contact details must be entered.

(6) Alternate Surrogate Address.

(7) Alternate Surrogate Phone.

Additional Instructions

(8) Optional Provisions. Be advised that this appointment of a Florida Health Care Surrogate may be reviewed with the assumption that the Surrogate is fully up-to-date and in agreement with the Principal’s health care preferences. Even when this is true, many would consider it wise of the Florida Principal to provide a detail of instructions or preferences regarding treatments he or she feels powerfully about or address certain scenarios that are particularly concerning to the Principal. An area where these details can be reported is included in this form since this document can only verify its content as the Florida Principal health care directive. Thus, if the Florida Principal wishes to set certain decisions to treatment options on paper, he or she is encouraged to do so. If more room is needed, then provided then the Florida Principal’s additional instructions can be continued on a separate sheet of paper then attached to this appointment.

Document Recipients

(9) Recipient Name. The Florida Principal should make sure that, in addition to his or her preferred Medical Facility and Health Care Surrogate, concerned Parties close to him or her are aware of the directives being set here. Thus, any Recipient who shall be presented with this document for storage or as an effort to solidify the Florida Principal’s medical preferences (i.e., Family Members) should be identified by name as the Recipient of this document.

(10) Recipient Address.

Florida Principal Signature

(11) Principal Signing.  The Florida Principal must sign this form once it has been completed. This signature will be verifiable by the Witnesses who observe it.

(12) Florida Principal’s Signature Date.

(13) Witness Signature. The two Parties who have watched this document’s execution must each sign their names as a Witness to the Florida Principal’s act of signing.

Acceptance Of Surrogate Of Designation

(14) Health Care Surrogate Name. The responsibilities a Health Care Surrogate is given can determine the longevity of the Principal’s life. The Florida Health Care Surrogate will need to formally accept such a responsibility. Therefore, a declaration of this acceptance has been provided but requires some preparation beginning with the Health Care Surrogate’s full name.

(15) Florida Principal Name.

(16) Health Care Surrogate Address.

(17) Health Care Surrogate Signature. The Florida Health Care Surrogate should sign and date the completed acceptance statement to establish his or her willingness to act in this role.

Living Will Declaration

(18) Declaration Date. The Florida Principal or the Florida Declarant issuing this directive package can include a set of instructions that life-prolonging treatment should be halted or denied should he or she be unable to communicate with attending Health Care Professionals while unable to live without medical treatment. His or her directives must be known to be the latest issued, thus, this document must be dated.

(19) Florida Declarant Name.

Medical Conditions Prompting These Directives

(20) Medical Condition Directive. The Florida Principal should mark every box that defines a medical condition in which he or she expects to prompt this document into action with the Medical Professionals reviewing it.

Health Care Surrogate

(21) Health Care Surrogate Identification. Naturally, if the Florida Principal has named a Health Care Surrogate, then attending Health Care Professionals will seek a conference with this Party (if appropriate). The full name of the Health Care Surrogate the Florida Principal wishes consulted where this document is concerned should be dispensed with his or her contact information.

(22) Surrogate Address.

(23) Surrogate Phone Number.Additional Instructions.

(24) Florida Declarant Directions. While this document gives a blanket statement regarding the withdrawal of life-support under the conditions the Florida Declarant has indicated, he or she can further define when medical care should cease focusing on longevity and when it should not. For instance, the Florida Declarant may wish to undergo a trial period, experimental treatments, or have certain comfort requirements met by Health Care Providers. Such preferences and directives should be documented in the space provided and, if necessary, continued in an attachment.

Signature

(25) Florida Declarant Signature. The Patient issuing the living will directives above must sign his or her name as the Florida Declarant before two witnessing Parties.

(26) Witness Signature And Contact Information. Both Witnesses, upon seeing the Florida Declarant complete signing his or her name, should then sign their own names as a testimony. Once done, each Witness should produce his or her full address immediately below his or her signature.

Florida Do Not Resuscitate Order

(27) Patient Name. The Florida Patient or Declarant can issue a general instruction to Responders and other Florida Health Care Providers that CPR or cardiopulmonary resuscitation should not be employed if his or her lungs and heart stop functioning. To issue this order the full name of the Florida Patient must be attached to this document.

(28) Document Date.

Patient Statement

(29) Signature Party Identity. In some cases, the Florida Declarant and Patient are two different Parties. For instance, the Florida Declarant may be composing this statement under the instructions of the Patient (who may be unconscious or lacks the motor coordination to work with this document). This can be a Health Care Surrogate, Court-Appointed Guardian, a Durable Attorney-in-Fact, or a Florida Proxy. If this is the case, then the category by which the Florida Declarant can be placed under should be selected from the choices presented.

 

Signature Execution

(30) Declarant Signature Requirement. This document must be signed by the Florida Patient or Declarant.

(31) Florida Declarant’s Printed Name.

Physician’s Statement

(32) Physician Signature And Date. Since a failure of the heart and lungs will usually result in death, a licensed Florida Physician must approve these orders as appropriate. He or she must sign this declaration to perform this action as well as report the date when he provided this signature

(33) Emergency Telephone Number. The Office, Institution, or Cell number the Florida Physician wishes used when information regarding an emergency, this Patient, and this declaration should be provided.

(34) Physician’s Printed Name. The Florida Physician’s name should be provided in print.

(35) Physician’s Credentials. A record of the Signature Physician’s medical license number is required with the Physician’s signature.

DNR Wallet Card

(36) Physician Signature And Contact. The Florida Declarant or Patient has the option of carrying a smaller version of the DNR in his or her wallet. This also acts as his or her order to not resuscitate and thus must be signed and dated by the Florida Physician above. Additionally, his or her emergency contact number, printed name, and Medical License number should be presented.

(37) Patient’s Full Name And Date. The wallet card for the DNR must document the Florida Patient’s full name and its document date.

(38) Patient’s Statement. If a Party has issued this DNR on behalf of the Patient then he or she must be identified as the Florida Patient’s Health Care Surrogate, Proxy, Court Appointed Guardian, or Durable Attorney-in-Fact by marking the appropriate box.

(39) Florida Patient Signature. This card must be signed by the Florida Declarant to be considered valid.

(40) Printed Name.

Florida Organ Donor Registration form

(41) Organ Donor Identification. The Florida Declarant or Principal of this form may also establish himself or herself as an Organ Donor in the State of Florida with a basic statement. Before employing this option, the Organ Donor’s Driver’s License, social security number, date of birth should be indicated as well as his or her sex.

(42) Organ Donor Name And Contact Information. The full name of the Organ Donor along with his or her address of residence is needed.

(43) Authorized Anatomical Gifts. The organs, tissues, body parts, and other anatomical gifts that can be made should be specified and approved by the Organ Donor. To this end, he or she only needs to mark the correct box to authorize any donation made upon death, that only a donation that he or she details with a list of approved anatomical gifts is approved, or to authorize his or her entire body to be donated as a whole for medical study.

(44) Limitations Or Special Wishes. Any legal limitations or special requests applicable to the anatomical gift authorization can be made by the Organ Donor.

(45) Nearest Relative Name. The Organ Donor’s nearest Relative should be identified by name and contact information.

Organ Donor Signature

(46) Signature Of Organ Donor. The form must be signed by the Organ Donor then dated immediately after signing.

(47) Witness Signature. The Witness observing the Organ Donor’s signature should sign and date this document. If the Organ Donor is a Minor, then he or she should sign the Witness line reserved for a Parent’s testimony.

Living Will Wallet Card

(48) Patient Name. In an effort to make sure that any Health Care Provider or First Responder in the State of Florida is aware of the Patient’s medical directives, a wallet card has been supplied to identify several facts beginning with the name of the Patient. It should be noted this first portion will identify that the Patient has issued a living will. If no such document is issued, then leave this first area unattended.

(49) Doctor’s Name And Phone Number. The Primary Physician of the Florida Patient or the Physician who has completed the Patient’s DNR should be identified by name and phone number.

Advance Directive Copies Wallet Card

(50) Storage Recipients. The name and address of two Parties who have received and store a copy of the Patient’s advance directives should be recorded.

Other Advance Directive

(51) Recipient Names. The next segment allows for the issuance of the Patient’s advance directive to be declared. His or her full name and contact material should be supplied.

Health Care Agent Wallet Card

(52) Florida Attorney-in-Fact’s Information. If the Florida Patient has named a specific Party to act as his or her Health Care Surrogate (also referred to as Health Care Agent), then the final segment of the wallet card should be used to document the name and telephone number(s) of the Florida Patient’s Health Care Surrogate as his or her Agent

 

 

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