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Florida Designation of Health Care Surrogate Form

The surrogate receives health care authority, with separate optional initials for immediate access to information and immediate decision-making.

Jurisdiction
Florida
Purpose
Medical & health care
Source / form version
Revised October 2021, printed on both pages.
Resource format
PDF
Signing
Sign before two adult witnesses. The surrogate cannot witness; at least one witness must be neither the principal’s spouse nor a blood relative.
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Sources checked: 2026-11-13. General information, not individual legal advice.

Choose a surrogate and alternate

The Florida designation names a person to help with health care decisions and an alternate if the first person cannot serve. This is separate from a living will’s treatment instructions. Use accurate contact details, discuss the appointment in advance, and identify any restrictions in the instructions area.

Sources: [1] [3] [4]

Decide when each authority begins

The form distinguishes immediate access to medical information from immediate authority to make health care decisions. Each has its own initial box. Without an immediate-authority choice, the decision-making power depends on the physician’s determination described in the form. Even where immediate authority is granted, your own capable decisions remain controlling.

Sources: [1] [3] [4]

Complete the witness page

The principal must sign in the presence of two adult witnesses. The appointed surrogate may not act as witness, and at least one witness must be unrelated by blood and not the principal’s spouse. Keep both pages and any instructions together. Give copies to the surrogate, alternate, and treating providers, and replace their copies when you change the designation.

Sources: [1] [3] [4]

Common questions

Do I need a notary for this Florida health care form?

The statutory surrogate designation uses two witnesses; it does not require a notarial acknowledgment. Financial POA signing rules are different.

Sources: [1] [3] [4]

Can I change the surrogate later?

Yes, while you have capacity. Florida §765.104 provides methods for revocation or amendment. Notify the surrogate and providers so they do not continue to rely on an outdated copy.

Sources: [1] [3] [4]

Related forms and guides

Sources and verification

  1. Florida Agency for Health Care Administration: source and instructions (opens in a new tab)
  2. Direct PDF (opens in a new tab)
  3. Florida Statutes §765.202 — designation (opens in a new tab)
  4. Florida Statutes §765.104 — revocation (opens in a new tab)

Primary publisher file and instructions checked on 2026-11-12. External link only; no independent attorney review or suitability determination is claimed.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.