FLORIDA DESIGNATION OF HEALTH CARE SURROGATE

(Healthcare Power of Attorney)

Effective Date: [DATE]
Principal: [PRINCIPAL LEGAL NAME], residing at [ADDRESS] (“Principal”)
Primary Surrogate: [PRIMARY SURROGATE LEGAL NAME], residing at [ADDRESS] (“Surrogate”)
First Alternate Surrogate: [FIRST ALTERNATE NAME] (optional)
Second Alternate Surrogate: [SECOND ALTERNATE NAME] (optional)

[// GUIDANCE: All bracketed terms must be completed or removed prior to execution.]

TABLE OF CONTENTS

1. Recitals
2. Definitions
3. Appointment & Grant of Authority
4. Scope of Health-Care Decision-Making Powers
5. End-of-Life Decisions
6. HIPAA Authorization
7. Durability; Effectiveness; Revocation
8. Nomination of Guardian
9. Good-Faith Standard; Indemnification; Liability Limitation
10. Dispute Resolution; Governing Law
11. General Provisions
12. Acceptance by Surrogate(s)
13. Execution & Attestation

1. RECITALS

A. This Designation of Health Care Surrogate (“Instrument”) is executed pursuant to, and shall be interpreted in accordance with, Fla. Stat. §§ 765.101–765.205.
B. Principal desires to designate the person(s) identified herein to make health-care decisions on the Principal’s behalf whenever the Principal is unable, or chooses not, to make those decisions personally.
C. Principal intends that this Instrument constitute a durable power of attorney for health-care decisions under the laws of the State of Florida.

2. DEFINITIONS

“Alternate Surrogate” means the person(s) named in Section 3.3 who shall act only if the Primary Surrogate is unwilling, unable, or unqualified to serve.
“Health-Care Decision” means consent, refusal to consent, withdrawal of consent, or any other decision relating to the Principal’s health care, including but not limited to the provision, withholding, or withdrawal of life-prolonging procedures.
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. Parts 160 & 164.
“Incapacity” has the meaning set forth in Fla. Stat. § 765.204.
“Good Faith” means honesty in fact in the conduct or transaction concerned.
All other capitalized terms shall have the meanings assigned in the context in which they appear.

3. APPOINTMENT & GRANT OF AUTHORITY

3.1 Appointment. Principal hereby appoints the Surrogate to act for the Principal with respect to all Health-Care Decisions.
3.2 Grant of Authority. Subject to the limitations expressly set forth herein, Surrogate is authorized to:
 a. Provide informed consent or refusal for any medical procedure, treatment, or intervention;
 b. Gain access to, and authorize disclosure of, medical and related information;
 c. Employ or discharge health-care providers;
 d. Approve or deny admission to or discharge from hospitals, nursing homes, hospice, assisted-living facilities, or similar institutions;
 e. Authorize pain relief and palliative care, including controlled substances;
 f. Receive and review medical records and information;
 g. Take all other actions reasonably necessary to carry out the foregoing powers.
3.3 Successor Appointment. If the Surrogate is unwilling, unable, or unqualified to serve, authority shall pass in the order listed below:
 i. First Alternate Surrogate;
 ii. Second Alternate Surrogate.

4. SCOPE OF HEALTH-CARE DECISION-MAKING POWERS

4.1 General Standard. Surrogate shall make decisions in Good Faith in accordance with the Principal’s known wishes; if unknown, in the Principal’s best interest.
4.2 Organ & Tissue Donation. [SELECT ONE: “Surrogate is authorized to consent to anatomical gifts” / “No authority granted.”]
4.3 Mental Health Treatment. [INCLUDE if Principal wishes to authorize/limit psychiatric or psychological treatment.]

5. END-OF-LIFE DECISIONS

5.1 Life-Prolonging Procedures. If Principal has an end-stage condition or is in a persistent vegetative state, and if the attending physician and another consulting physician have determined there is no reasonable medical probability of recovery:
 a. [SELECT ONE:]
  1. Surrogate shall authorize withholding or withdrawal of life-prolonging procedures; or
  2. Surrogate shall not authorize withholding or withdrawal of life-prolonging procedures.
5.2 Artificial Nutrition & Hydration. [SELECT ONE: “May be withheld/withdrawn” / “Must be continued.”]
5.3 Pain Management. Surrogate is expressly authorized to approve administration of medication in doses necessary for pain alleviation even if such action may hasten death.

[// GUIDANCE: Section 5 constitutes a “living will” component; delete if a separate living-will instrument will be used.]

6. HIPAA AUTHORIZATION

6.1 Authorization. In accordance with 45 C.F.R. § 164.508(c), Principal authorizes any Covered Entity to disclose to the Surrogate and any Alternate Surrogate all “Protected Health Information” regarding the Principal.
6.2 Purpose. Disclosure is authorized to enable the Surrogate to make informed Health-Care Decisions.
6.3 Expiration. This authorization is effective upon execution and shall not expire unless revoked pursuant to Section 7.

7. DURABILITY; EFFECTIVENESS; REVOCATION

7.1 Durability. This Instrument is intended to be, and shall be construed as, a durable power of attorney that is not affected by Principal’s subsequent incapacity.
7.2 Effectiveness. [SELECT ONE:]
 a. “This Instrument becomes effective immediately upon execution.”
 b. “This Instrument becomes effective only upon a written determination of Incapacity as defined herein.”
7.3 Revocation. Principal may revoke this Instrument in whole or in part by (i) a signed writing delivered to the Surrogate, or (ii) personally informing the attending physician of the revocation, consistent with Fla. Stat. § 765.104.

8. NOMINATION OF GUARDIAN

If a court decides that the appointment of a guardian of the person or property of the Principal is necessary, Principal nominates the Surrogate (or, if unable, the Alternate Surrogate then serving) to serve in that capacity, consistent with Fla. Stat. § 744.3045.

9. GOOD-FAITH STANDARD; INDEMNIFICATION; LIABILITY LIMITATION

9.1 Good-Faith Reliance. Any third party may rely on representations by the Surrogate as to all matters relating to powers granted herein without duty of further inquiry, provided such reliance is in Good Faith.
9.2 Indemnification. Principal agrees to indemnify and hold harmless the Surrogate and any Alternate Surrogate from any loss, liability, or expense, including reasonable attorneys’ fees, incurred as a result of actions taken in Good Faith pursuant to this Instrument.
9.3 Liability Cap. No Surrogate shall be liable to the Principal or to any third party for monetary damages except for acts or omissions constituting bad faith, gross negligence, or willful misconduct.

10. DISPUTE RESOLUTION; GOVERNING LAW

10.1 Governing Law. This Instrument shall be governed by and construed in accordance with the health-care advance-directive laws of the State of Florida, without regard to conflict-of-laws principles.
10.2 Forum Selection. Any judicial proceeding arising under or relating to this Instrument shall be brought exclusively in the state probate court having jurisdiction over the Principal’s domicile at the time of filing.
10.3 Arbitration & Jury Waiver. Arbitration is not available, and the parties do not waive trial by jury.
10.4 Injunctive Relief. Nothing herein shall limit the right of any interested person to seek injunctive or declaratory relief to enforce or clarify this Instrument.

11. GENERAL PROVISIONS

11.1 Copies. Photographic, facsimile, or electronically stored copies of this executed Instrument shall be as valid as the original.
11.2 Severability. Should any provision be held unenforceable, the remaining provisions shall continue in full force.
11.3 Amendment. Principal may amend this Instrument only by a subsequent written instrument executed with the formalities required for an advance directive under Florida law.
11.4 Entire Instrument. This Instrument constitutes the entire designation of health-care surrogate and supersedes all prior inconsistent directives executed by the Principal.
11.5 Electronic Signatures. An electronic signature that complies with applicable Florida law shall be deemed an original.

12. ACCEPTANCE BY SURROGATE(S)

Each undersigned Surrogate acknowledges appointment, accepts the duties imposed, and agrees to act in accordance with this Instrument and applicable law.

13. EXECUTION & ATTESTATION

Signed this ___ day of _, 20.

PRINCIPAL

[PRINCIPAL NAME], Principal

WITNESSES

1. ____ Date: _
    Printed Name: __
2. ____ Date: _
    Printed Name: __

[// GUIDANCE: 1) The Surrogate may not serve as a witness.
2) At least one witness must be neither the Principal’s spouse nor a blood relative.]

NOTARY ACKNOWLEDGMENT (Optional)

State of Florida County of _
The foregoing instrument was acknowledged before me on _, 20, by [PRINCIPAL NAME], who is personally known to me or who produced ___ as identification.

Notary Public – State of Florida
My Commission Expires: ____

SURROGATE ACCEPTANCE

I, [SURROGATE NAME], accept the foregoing appointment.
_____  Date: ____

ALTERNATE SURROGATE ACCEPTANCE(S) (if any)

I, [FIRST ALTERNATE NAME], accept the foregoing appointment.
_____  Date: ____

I, [SECOND ALTERNATE NAME], accept the foregoing appointment.
_____  Date: ____

[// GUIDANCE:

• Review Sections 5 and 7 carefully with the client—Florida law requires clarity on end-of-life intentions and effective-date options.
• Verify witness eligibility to avoid later challenges to validity.
• Provide executed copies to the Principal’s primary physician and keep a copy with estate-planning documents.
• Consider adding mental-health-treatment language if the Principal wishes to authorize ECT, psychoactive medication, or other psychiatric interventions.
• For clients owning out-of-state property or spending significant time outside Florida, discuss executing compatible advance-directive forms in those other jurisdictions.]