Declaration of Medical Proxy - northfloridaopg.org

1 85A Manual for Individuals and Families. D eclaration o f Medical P roxy Under Florida S tatute 7 01, a Medical p roxy can b e a ppointed t o make health c are d ecisions f or an incapacitated o r d evelopmentally d isabled p atient i f t here i s n o e xecuted advance d irective, i f t here is n o designated s urrogate o r a lternate s urrogate t o e xecute a n a dvance d irective, or i f t he d esignated o r a lternate surrogate i s n o l onger available t o make h ealth c are d ecisions. Health c are d ecision means p roviding i nformed consent, r efusal o f c onsent or w ithdrawal o f c onsent to a ny and all h ealth c are; d ecisions concerning p rivate, public, g overnment, or v eteran s b enefits t o d efray t he cost o f health c are a nd t he right o f a ccess t o a ll r ecords o f t he p rincipal r easonably necessary f or a Medical p roxy t o make d ecisions i nvolving h ealth c are. Health c are decisions may b e made for the p atient b y a ny o f t he f ollowing individuals, i n t he f ollowing o rder o f p riority, i f n o i ndividual i n a p rior c lass i s r easonably a vailable, willing, or competent t o a ct.

2 Please check t he appropriate p roxy c ategory you are s igning u nder: A c ourt a ppointed guardian o r guardian a dvocate; The p atient s s pouse; An a dult c hild o f t he p atient o r t he majority t hereof; A p arent o f t he p atient; An a dult s ibling o f t he p atient o r t he majority t hereof; An a dult r elative o f t he p atient w ho h as e xhibited s pecial c are and c oncern for t he p atient; A c lose f riend o f t he p atient; o r A l icensed c linical s ocial w orker o r a c linical s ocial w orker who i s a graduate o f a court-approved guardianship p rogram s elected b y a b ioethics c ommittee. The p atient s a ttending p hysician s hould e valuate the p atient s c apacity a nd i f t he p hysician c oncludes t he patient h as c apacity t o make h ealth c are d ecisions, t he a ttending p hysician s hould e nter t hat e valuation i n t he patient s r ecord. If t he a ttending p hysician q uestions c apacity, a s econd p hysician c an a lso b e c onsulted.

3 I, _____, Medical p roxy, c onfirm t hat t he a bove c onditions h ave b een met f or t he patient, _____, a nd t hat t here are n o available s urrogates t o b e c onsidered f rom a p rior c lass a ccording to t his s tatute. Therefore, I accept t he d esignation of Medical P roxy f or t he patient n amed a bove. I a gree t o make h ealth c are d ecisions b ased u pon w hat I reasonably b elieve t he p atient w ould make u nder t he circumstances. I a ccept t he r esponsibilities o f Medical P roxy as a uthorized u nder F lorida S tatute 7 01. _____ _____ Medical P roxy S ignature Date STATE OF FLORIDA COUNTY O F _ _____ Sworn t o ( or a ffirmed) and s ubscribed b efore me this _ ___ d ay o f _ _____, ____, by _____. _____ Notary P ublic S ignature _____ Print, Type o r S tamp Commissioned N ame o f N otary Personally K nown _ _____ O R P roduced Identification _ _____ T ype o f Identification Produced _ _____