Florida Healthcare Surrogate Designation

Designation of Healthcare Surrogate — Prepared under Florida Statutes §765.101 et seq. This document authorizes a person you trust to make healthcare decisions on your behalf if you become unable to do so. Must be signed before two witnesses (Fla. Stat. §765.202).

Your Information (Principal)

The person making this designation. You must be a competent adult (Fla. Stat. §765.101).

Full Legal Name *

Date of Birth *

County of Residence *

City *

Your Healthcare Surrogate

The person you authorize to make medical decisions on your behalf. Your surrogate cannot also be a witness to this document (Fla. Stat. §765.202(2)).

Who should I choose? A trusted adult who knows your wishes — spouse, adult child, sibling, or close friend. They must be willing to advocate for you under difficult circumstances.

Full Name *

Relationship to You *

Phone Number

Address

Alternate Healthcare Surrogate

If your first surrogate is unable or unwilling to act, this person steps in (Fla. Stat. §765.202(3)).

Full Name

Relationship to You

Phone Number

Address

Authority & Scope

Define when and how broadly your surrogate may act.

When does surrogate authority begin? *

Only upon my incapacity

Authority activates only when my attending physician determines I lack capacity to make informed healthcare decisions (Fla. Stat. §765.204). Recommended for most people.

Immediately — without requiring a determination of incapacity

My surrogate may act on my behalf at any time. Useful if I want my surrogate to have immediate access to my health information (Fla. Stat. §765.202(6)).

Life-Prolonging Procedures

Florida Statute §765.101 distinguishes three conditions:
• Terminal Condition — an end-stage condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery
• End-Stage Condition — an irreversible condition that has resulted in progressively severe and permanent deterioration
• Persistent Vegetative State — a permanent and irreversible condition of unconsciousness

My surrogate decides — consistent with my known wishes

Continue all life-prolonging treatment

Withdraw life-prolonging treatment if I am in a terminal condition with no reasonable probability of recovery

Mental Health Treatment

Include mental health treatment decisions

My surrogate may make decisions regarding mental health treatment as provided under Fla. Stat. §394.4598.

Exclude mental health treatment decisions

Health Information Access (HIPAA)

Authorize your surrogate to receive your medical records and health information.

HIPAA Authorization *

Full access to all health information

My surrogate may receive, review, and disclose all of my protected health information from any healthcare provider, consistent with their authority under this designation.

Limited to information necessary to make healthcare decisions

Special Instructions (Optional)

Any specific wishes regarding your healthcare, values, or religious beliefs that should guide your surrogate's decisions.

Special Instructions or Values

This is guidance for your surrogate — not a limitation on their authority. The more specific you are, the better they can advocate for you.

Organ & Tissue Donation

I wish to donate organs and tissue upon my death

I do not wish to donate organs or tissue

I leave this decision to my surrogate

✓

Florida Signing Requirements

Fla. Stat. §765.202 — Must be signed before two adult witnesses.

⚠️ Your surrogate cannot be a witness. At least one witness must be neither your spouse nor a blood relative (Fla. Stat. §765.202(2)).

Step 1 — Sign in the presence of two adult witnesses.

Step 2 — Both witnesses sign in your presence.

Step 3 — Provide an exact copy to your surrogate (Fla. Stat. §765.202(1)).

Step 4 — Give a copy to your primary care physician for your medical file.

Step 5 — Keep the original in a safe, accessible location. Tell your surrogate where it is.

Note: A notary is NOT required for a Healthcare Surrogate designation under Florida law — two witnesses are sufficient. However, notarization is optional and may be added for extra reliability.

Complete all fields, then download your document.