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The Florida Statutes

The 2023 Florida Statutes (including Special Session C)

Title XLIV
CIVIL RIGHTS
Chapter 765
HEALTH CARE ADVANCE DIRECTIVES
View Entire Chapter
F.S. 765.2038
765.2038 Designation of health care surrogate for a minor; suggested form.A written designation of a health care surrogate for a minor executed pursuant to this chapter may, but need not, be in the following form:

DESIGNATION OF HEALTH CARE SURROGATE
FOR MINOR

I/We,   (name/names)  , the [ ] natural guardian(s) as defined in s. 744.301(1), Florida Statutes; [ ] legal custodian(s); [ ] legal guardian(s) [check one] of the following minor(s):

       ;

       ;

       ,

pursuant to s. 765.2035, Florida Statutes, designate the following person to act as my/our surrogate for health care decisions for such minor(s) in the event that I/we am/are not able or reasonably available to provide consent for medical treatment and surgical and diagnostic procedures:

Name:   (name)  

Address:   (address)  

Zip Code:   (zip code)  

Phone:   (telephone)  

If my/our designated health care surrogate for a minor is not willing, able, or reasonably available to perform his or her duties, I/we designate the following person as my/our alternate health care surrogate for a minor:

Name:   (name)  

Address:   (address)  

Zip Code:   (zip code)  

Phone:   (telephone)  

I/We authorize and request all physicians, hospitals, or other providers of medical services to follow the instructions of my/our surrogate or alternate surrogate, as the case may be, at any time and under any circumstances whatsoever, with regard to medical treatment and surgical and diagnostic procedures for a minor, provided the medical care and treatment of any minor is on the advice of a licensed physician.

I/We fully understand that this designation will permit my/our designee to make health care decisions for a minor and to provide, withhold, or withdraw consent on my/our behalf, to apply for public benefits to defray the cost of health care, and to authorize the admission or transfer of a minor to or from a health care facility.

I/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate:

Name:   (name)  

Name:   (name)  

Signed:   (signature)  

Date:   (date)  

WITNESSES:

1.   (witness)  

2.   (witness)  

History.s. 11, ch. 2015-153; s. 86, ch. 2016-10.