Power of Attorney Form Florida for Medical

DESIGNATION OF HEALTH CARE SURROGATE AND MEDICAL POWER OF ATTORNEY

Document ID: FL-MPOA-2026-V1.0
Effective Date: [Effective Date]
Governing Jurisdiction: State of Florida (Chapter 765, Florida Statutes)
Version: 1.0 (Institutional Form)

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SECTION 1: STATUTORY & LEGAL COMPLIANCE NOTICE

CRITICAL CLINICAL AND JURISDICTIONAL DISCLAIMER:
This instrument is structured to comply strictly with the requirements of Chapter 765 of the Florida Statutes governing Health Care Advance Directives. This document grants the designated Health Care Surrogate broad legal authority to make health care decisions, grant or withhold consent to medical procedures, and access protected health information on behalf of the Principal. This document must be executed in accordance with Florida law, requiring the signature of the Principal and the attestation of two subscribing witnesses, at least one of whom is neither the spouse nor a blood relative of the Principal. Clinical execution requires careful review by the Principal and the designated Surrogate to ensure mutual understanding of treatment philosophies, life-prolonging procedures, and end-of-life care preferences.

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SECTION 2: PARTIES & RECITALS

This Designation of Health Care Surrogate and Medical Power of Attorney (the "Instrument") is made and entered into on [Effective Date], by and between:

• Principal: [Principal Full Legal Name], residing at [Principal Address], hereinafter referred to as the "Principal."
• Primary Health Care Surrogate: [Surrogate Full Legal Name], residing at [Surrogate Address], with telephone number [Surrogate Phone Number] and email address [Surrogate Email], hereinafter referred to as the "Surrogate."
• Alternate Health Care Surrogate: [Alternate Surrogate Full Legal Name], residing at [Alternate Surrogate Address], with telephone number [Alternate Surrogate Phone Number] and email address [Alternate Surrogate Email], hereinafter referred to as the "Alternate Surrogate."

RECITALS:
WHEREAS, the Principal desires to designate a trusted representative to make health care decisions and act as a medical attorney-in-fact in the event the Principal is rendered incapacitated or otherwise unable to provide informed consent for medical treatment; and
WHEREAS, the Principal intends for this Instrument to operate pursuant to the provisions of Chapter 765, Florida Statutes, and to be interpreted broadly to effectuate the Principal’s expressed medical wishes;
NOW, THEREFORE, the Principal hereby revokes any prior designations of health care surrogates or medical powers of attorney executed heretofore and appoints the Surrogate under the terms and conditions set forth below.

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SECTION 3: EXHAUSTIVE OPERATIVE CLAUSES & LEGAL TERMS

3.1 Grant of Authority and Scope of Agency

The Principal hereby designates and appoints the Surrogate as the Principal’s true and lawful attorney-in-fact and health care surrogate, granting the Surrogate full power and authority to act for the Principal in all health care matters. This authority shall become effective immediately upon a determination by the Principal’s attending physician that the Principal lacks the capacity to make informed health care decisions, or upon such other trigger event as specified herein. The Surrogate is authorized to:

1. Provide, withhold, or withdraw consent to any and all types of medical care, treatments, surgical procedures, diagnostic tests, medication, and institutional placement.
2. Employ and discharge physicians, psychiatrists, dentists, nurses, therapists, and other health care professionals.
3. Access, review, and copy all medical records, health information, and clinical notes protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any other applicable state or federal privacy statutes.
4. Apply for public or private health care benefits, execute insurance claims, and negotiate financial settlements relating to medical treatment.

3.2 Limitation on Authority

Notwithstanding the broad grant of authority in Section 3.1, the Surrogate shall not have the authority to consent to any of the following treatments or procedures on behalf of the Principal, unless expressly authorized herein:

1. Abortion, except as necessary to preserve the life of the Principal.
2. Sterilization.
3. Electroconvulsive treatment (ECT).
4. Psychosurgery or experimental psychosurgery.
5. Voluntary admission to a mental health facility for psychiatric care, except as authorized under Chapter 394, Florida Statutes.

3.3 End-of-Life Decisions and Life-Prolonging Procedures

In the event that the Principal has a terminal condition, has suffered an end-stage condition, or is in a persistent vegetative state, and two attending physicians have determined that there is no reasonable medical probability of recovery, the Surrogate is authorized to make decisions regarding the withholding or withdrawal of life-prolonging procedures. This includes, but is not limited to, artificial nutrition and hydration, mechanical ventilation, and cardiopulmonary resuscitation. The Surrogate shall make these decisions in accordance with the known wishes of the Principal, or, if the Principal's wishes are unknown, in accordance with the Surrogate's assessment of the Principal's best interests.

3.4 HIPAA Waiver and Release of Protected Health Information

The Principal expressly directs all health care providers, physicians, hospitals, clinics, insurance companies, and medical data repositories to disclose to the Surrogate all individually identifiable health information and medical records requested by the Surrogate. This release is executed pursuant to 45 C.F.R. § 164.508 and is intended to serve as a fully compliant HIPAA authorization, empowering the Surrogate to act as the Principal's personal representative for all health information privacy purposes.

3.5 Appointment of Alternate Surrogate

If the Primary Surrogate named herein is unwilling, unable, or disqualified by law to serve, or resigns, the Principal hereby designates the Alternate Surrogate to act in the place and stead of the Primary Surrogate. The Alternate Surrogate shall possess all powers, rights, and immunities granted to the Primary Surrogate under this Instrument.

3.6 Compensation, Expenses, and Reimbursement

The Surrogate shall serve in this capacity without compensation for personal services rendered. However, the Surrogate shall be entitled to immediate and complete reimbursement from the assets of the Principal, or from any estate of the Principal, for all reasonable out-of-pocket expenses, travel costs, administrative fees, and legal expenditures incurred directly in the execution of the Surrogate's duties under this Instrument.

3.7 Term, Revocation, and Termination

This Instrument shall remain in full force and effect from the Effective Date until revoked by the Principal. The Principal retains the absolute legal right to revoke this Instrument at any time, and in any manner, regardless of the Principal's mental or physical capacity, by communicating an intent to revoke to the Surrogate, an attending physician, or a health care facility, or by executing a subsequent written instrument of revocation. Marriage dissolution or a judgment of annulment between the Principal and the Surrogate shall operate as an immediate revocation of this designation.

3.8 Representations and Warranties

The Principal represents and warrants that the Principal is of sound mind, possesses full legal capacity to execute this Instrument, and is acting knowingly, voluntarily, and free from duress, fraud, or undue influence. The Surrogate, by accepting this appointment, signifies willingness to serve and acknowledges an affirmative fiduciary duty to act in good faith and in strict accordance with the Principal's expressed instructions and best interests.

3.9 Limitation of Liability and Indemnification

No health care provider, facility, or third party who relies in good faith upon the authority granted under this Instrument shall incur any criminal or civil liability for acting in accordance with the instructions of the Surrogate. Furthermore, the Principal hereby releases, holds harmless, and agrees to indemnify the Surrogate from and against any and all claims, liabilities, losses, damages, or expenses arising out of any good-faith action taken or omitted by the Surrogate pursuant to this Instrument, excepting only acts of gross negligence, willful misconduct, or intentional bad faith.

3.10 Dispute Resolution and Governing Law

This Instrument, and all questions concerning its validity, construction, interpretation, and enforcement, shall be governed by, construed, and enforced in accordance with the laws of the State of Florida, specifically Chapter 765, Florida Statutes, without regard to its conflict of laws principles. Any legal action, dispute, or proceeding arising out of or relating to this Instrument shall be brought exclusively in the appropriate circuit court of competent jurisdiction within the State of Florida.

3.11 Miscellaneous Provisions

1. Severability: If any provision of this Instrument is held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, such provision shall be modified to the minimum extent necessary to make it valid and enforceable, and the remaining provisions shall remain in full force and effect.
2. Counterparts: This Instrument may be executed in multiple counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. Facsimile, electronic, and digital signatures shall have the same legal force and effect as original wet-ink signatures.
3. Entire Agreement: This Instrument constitutes the entire agreement and understanding between the Principal and the Surrogate regarding the subject matter hereof, superseding all prior oral or written representations, agreements, or advance directives.

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SECTION 4: EXECUTION & FORMAL SIGNATURE BLOCKS

IN WITNESS WHEREOF, the Principal has executed this Designation of Health Care Surrogate and Medical Power of Attorney on the date first written above.

FOR THE PRINCIPAL:
Signature: _____________________________________
Printed Name: [Principal Full Legal Name]
Address: [Principal Address]
Date: [Date]

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STATEMENT OF WITNESSES

The undersigned witnesses, each being over the age of eighteen (18) years, hereby certify that the Principal signed and executed this Instrument in our presence, that the Principal appeared to be of sound mind and under no duress, fraud, or undue influence, and that neither of us is the designated health care surrogate or alternate surrogate, nor the spouse or a blood relative of the Principal.

WITNESS 1:
Signature: _____________________________________
Printed Name: [Witness 1 Full Name]
Address: [Witness 1 Address]
Date: [Date]

WITNESS 2:
Signature: _____________________________________
Printed Name: [Witness 2 Full Name]
Address: [Witness 2 Address]
Date: [Date]

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ACCEPTANCE OF APPOINTMENT BY SURROGATE

I, [Surrogate Full Legal Name], the primary health care surrogate designated herein, hereby acknowledge and accept this appointment. I agree to serve faithfully as the health care surrogate for the Principal, to act in accordance with the Principal's instructions and best interests, and to discharge my fiduciary duties pursuant to Chapter 765, Florida Statutes.

Signature: _____________________________________
Printed Name: [Surrogate Full Legal Name]
Date: [Date]

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SECTION 5: STEP-BY-STEP EXECUTION & FILING GUIDE

1. Document Preparation: Copy and paste this text into Microsoft Word or Google Docs. Replace all bracketed text (e.g., [Principal Full Legal Name], [Principal Address], [Effective Date]) with precise, legally accurate information matching the Principal's government-issued identification.
2. Review of Terms: The Principal and the designated Surrogate must review all operative clauses, particularly regarding life-prolonging procedures and end-of-life care, to ensure complete alignment of intent and clinical expectations.
3. Signatory Verification: Ensure that two independent witnesses are present at the time of execution. Per Florida law, neither witness may be the designated Surrogate or Alternate Surrogate, nor may either witness be related to the Principal by blood or marriage.
4. Execution Protocol:
   • The Principal must sign and date the document in the presence of both witnesses.
   • Both witnesses must sign and print their names and addresses immediately following the Principal's execution.
   • The primary Surrogate should sign the Acceptance of Appointment section to evidence formal consent to the role.
5. Digital or Wet-Ink Execution: While wet-ink signatures witnessed in person are universally accepted by all medical institutions in Florida, electronic signature platforms (such as DocuSign or Adobe Sign) may be utilized if compliant with state electronic notarization and witness statutes. For maximum clinical acceptance, in-person execution with physical witnesses is strongly recommended.
6. Record Retention & Distribution:
   • The Principal must retain the original executed document in an easily accessible, secure location (not a safe deposit box).
   • Provide certified copies of this Instrument to the primary Surrogate, the alternate Surrogate, the Principal's primary care physician, and any hospitals or medical groups where the Principal receives regular treatment.
   • Keep a digital copy accessible via smartphone or cloud storage for emergency medical situations.