Designation Of Health Care Surrogate Effective Immediately Option {G-1.030}

DESIGNATION OF HEALTH CARE SURROGATE (EFFECTIVE IMMEDIATELY) I, 765.202, Florida Statutes: Name: Address: Telephone: If my health care surrogate is not willing, able, or reasonably available to perform his or her duties, I designate as my alternate health care surrogate: Name: Address. Telephone: INSTRUCTIONS FOR HEALTH CARE , designate as my health care surrogate under s. I authorize my health care surrogate to: _____ Receive any of my health information, whether oral or recorded in any form or medium, that: (initials) 1. Is 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. Relates to my past, present, or future physical or mental health or condition; the provision of health care to me; or the past, present, or future payment for the provision of heath care to me. I further authorize my health care surrogate to: _____ Make all health care decisions for me, which means he or she has the authority to: (initials) 1. Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care, including life prolonging procedures. 2. Apply on my behalf for private, public, government, or veterans' benefits to defray the cost of health care. 3. Access my health information reasonably necessary for the health care surrogate to make decisions involving my health care and to apply for benefits for me. 4. Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes. _____ Specific instructions and restrictions: (initials) Bar Form No. G-1.030 © Florida Lawyers Support Services, Inc. January 1, 2024 www.FormsWorkflow.com