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Florida Medical Power of Attorney Form | Designation of Health Care Surrogate

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Florida Medical Power of Attorney Form | Designation of Health Care Surrogate

Updated August 08, 2023

A Florida medical power of attorney, or ‘Florida designation of health care surrogate’ or ‘advance directive’, allows a person to appoint a surrogate and an alternate surrogate to make health care judgments if the principal (issuing party) suffers a medical event where he or she is unable to communicate healthcare wishes to health care providers. This form allows the principal to appoint someone who knows his or her preferences for medical treatment and is able to step in when the need arises.

Living Will – If the principal is only seeking to make the end-of-life treatment options. (§ 765.303).

How to Write

Download: PDF

1 – Designate A Health Care Surrogate Using The Document On This Page

You may download the appointment template to name a Surrogate using the buttons presented with the preview picture of this paperwork. You may fill this out either by printing an PDF through your browser or opening it with a compatible program then supplying the requested information onscreen. It is strongly recommended the Principal pay close attention to the information provided on the first page.

2 – The Principal And The Health Care Surrogate(s) Must Be Identified By Role

Once the Principal has read the first page and had a frank discussion with an appropriate professional (i.e. attorney, doctor, etc.) regarding the effect of this document, it will be time to supply the information it requests in the designated areas. First, locate the first two blank lines “Name” and “Age” in the first paragraph. Fill in the Full Legal Name of the Principal on the “Name” line and his or her current “Age” on the blank line following it. The Principal in this paperwork will be the individual who wishes his or her Health Care Instructions followed even when unconscious or unable to communicate.

Below this first paragraph, we will need to name the Health Care Surrogate or Health Care Agent who the Principal wishes to represent his or her wishes to others. The Legal Name of the Health Care Surrogate will need to be documented on the blank line labeled “Name” under the words “…To Make Health Care Decisions.”

On the line adjacent to the Health Care Surrogate Name, indicate the “Relationship” the Health Care Surrogate shares with the Principal. For instance, he or she may be the Principal’s Offspring, Parent, Grandparent, etc.

Next, we will need to report a reliable means of contact. Begin by entering the Health Care Surrogate’s Work Number on the blank line labeled “Phone (w)” and his or her Home Phone Number on the blank line labeled “(h)” below this.

Below the Health Care Surrogate’s Name, enter the Physical Address where he or she lives on the “Address” line.

The Principal and the Health Care Surrogate are not necessarily the only parties that need to be named in this document. If the Principal has the foresight to elect one or two back up Agents or Alternate Health Care Surrogate(s) to assume Principal Health Care Powers if/when the Health Care Surrogate above does not, will not, or cannot act as the Principal’s Health Care Surrogate, this Alternate Agent’s Name must be documented as well. To satisfy such a requirement, locate the statement “If My Surrogate Is Unwilling Or Unable…” then enter the Alternate Agent’s Legal Name, Relationship to the Principal, Work Phone Number, Home Phone Number, and Address. Each one of these items will have a clearly labeled blank line calling for this information.

3 – Any Specific Principal Directives Must Be Included Before The Principal Signing

The Principal will be giving a wide scope of Health Care Powers to the Health Care Surrogate when executing this document. It will be assumed by others the Principal and the Health Care Surrogate have captured all the Principal’s wishes. Generally speaking, it would be considered a wise course of action if the Principal solidified his or her directives concerning various scenarios, any limitations/restrictions that should be placed on the Health Care Surrogate’s Principal Powers, or any specific instructions and concerns by documenting them here. To provide such information locate the blank line labeled “Additional Instructions (Optional)” then enter such directives or cite a labeled/signed/dated attachment containing these directives and attached to this document.

4 – Two Witnesses Must Watch The Principal Sign This Delegation

This paperwork will not be considered valid unless it has been signed by the Principal after it has been completed. This task should be performed by the Principal before two Witnesses. At least one Witness must not be related to the Principal (familial), a beneficiary in any way, or anyone associated with a Health Care Service the Principal patronizes (i.e. doctors, hospitals, insurance companies). There will be a defined area for these parties to produce their signatures below the statement beginning with the words “I Further Affirm That This Delegation…” Here, the Principal must sign the blank line labeled “Signature” then enter the current Date on the blank line below this.

After he or she has signed it, the Principal should surrender this document to the two Witnesses. Each one must sign his or her Name on a unique “Witness” line.

5 – Supplying Directives For The Living Will

The next portion of this document will supply the language necessary to set up a Living Will where the Principal will make it known that certain medical events will result in a desire to withhold treatment and restrain the Medical Staff from prolonging his or her life with Medical Intervention/Procedures/Treatment. Some statements here, however, will not apply without the Principal’s initials.

If the Principal wishes to withhold Life-Prolonging procedures should he or she contract a Terminal Illness where no cure is available and his or her means of communication have been severely compromised or terminated then, the Principal must initial the blank line that precedes the sentence beginning with “Due To A Debilitating Disease Condition…”

If there are other scenarios where the Principal wishes Life-Prolonging Procedures withheld, these scenarios should be discussed on the blank line after the words “Specify Other Condition” then the Principal should initial the blank line just before this term.

In the next statement, the Principal should either initial the first blank line to indicate he or she would like to receive Artificial Nutrition/Hydration even if its only purpose is to prolong life or initial the second blank line if he or she would like Artificial Nutrition/Hydration withheld when its only purpose is to prolong life.

The Principal can include “Additional Instructions (Optional)” to this Living Will concerning end-of-life Medical Events and scenarios by having them reported on the blank line provided. If more room is required such directives may be included in an attachment.

The bottom of this page will provide an area, so the Principal and two Witnesses may supply their Signatures. The Principal will need to sign his or her Name on the “Signature” line then enter the Date of this Signature on the “Date” line in the lower right-hand corner.

Each of the two blank “Witness” lines in the lower left-hand corner of this page will require a Signature of one Witness to the Principal Act of Signing.