The person designated as Surrogate cannot act as Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. I further authorize my health care surrogate to: (Initials required in the blank space below.) _____ Make all health care isions for me, which means he or she has the authority toProvide informed consent, refusal of consent, or health care isions 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. I authorize my health care surrogate to: (Initials required in blank spaces below.) Relates to my past, present, or future physical or Access my health information reasonably necessary for the health care surrogate to make isions involving my health care and to apply for benefits for me. I fully understand that this designation will permit my designee to make health care isions and to provide, withhold, or withdraw consent on my behalf; to apply for public Designation of Health Care Surrogate. Additional instructions (optional): Produced for the Florida Developmental Disabilities Council By Program Design, Inc/03 I authorize my health care surrogate to: _____ (Initial Here) Receive health information whether oral or recorded in any form or medium, thatIs created or received by a health care provider, health care facility, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; AND 2 How do I designate a Health Care Surrogate? ide to make an Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one The person present has a DESIGNATION OF HEALTH CARE SURROGATE FOR TREATMENT OF MINOR CHILD* in their name from the parent or guardian, I authorize my health care surrogate to: INSTRUCTIONS FOR HEALTH CARE duties, I designate as my alternate health care surrogate: If my health care surrogate is not willing, able, or reasonably availableto perform his or her Phone: _____ Name: _____ Statutes: I, _____, designate as my health care surrogate under s., Florida of health care to me; or the past, present, or future payment for the provision of health care to me.
The person designated as Surrogate cannot act as Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. I further authorize my health care surrogate to: (Initials required in the blank space below.) _____ Make all health care isions for me, which means he or she has the authority toProvide informed consent, refusal of consent, or health care isions 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. I authorize my health care surrogate to: (Initials required in blank spaces below.) Relates to my past, present, or future physical or Access my health information reasonably necessary for the health care surrogate to make isions involving my health care and to apply for benefits for me. I fully understand that this designation will permit my designee to make health care isions and to provide, withhold, or withdraw consent on my behalf; to apply for public Designation of Health Care Surrogate. Additional instructions (optional): Produced for the Florida Developmental Disabilities Council By Program Design, Inc/03 I authorize my health care surrogate to: _____ (Initial Here) Receive health information whether oral or recorded in any form or medium, thatIs created or received by a health care provider, health care facility, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; AND 2 How do I designate a Health Care Surrogate? ide to make an Under Florida law, designation of a Health Care Surrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one The person present has a DESIGNATION OF HEALTH CARE SURROGATE FOR TREATMENT OF MINOR CHILD* in their name from the parent or guardian, I authorize my health care surrogate to: INSTRUCTIONS FOR HEALTH CARE duties, I designate as my alternate health care surrogate: If my health care surrogate is not willing, able, or reasonably availableto perform his or her Phone: _____ Name: _____ Statutes: I, _____, designate as my health care surrogate under s., Florida of health care to me; or the past, present, or future payment for the provision of health care to me.
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