Florida Medical Power of Attorney Form

The Florida medical power of attorney form is a legal document which will grant the Principal the right to transfer medical powers to another person also known to be the Attorney In Fact/Agent. Medical powers may be as limited or as broad as the Principal would choose to allow the agent. The Principal’s transfer of medical powers to the Attorney-in-Fact begin immediately with authorization of this document or any date specified by the Principal, and will remain in effect unless it is revoked by the principal, as long as the principal is competent to provide revocation in writing to the Agent(s). This form is for assistance with medical decisions only. (See:  Title XLIV – Chapter 765 Health Care Directives )

How To Write

Step 1 – Download the document and begin reviewing the pages at the bottom of the form so that you may better understand the terms included in this document

Step 2 – Appointment of Surrogate for Health Care Decisions By the Principal

  • Principal – 
  • Enter the Name of Principal into the First Line of the Document
  • Medical Surrogate/Agent –
  • Name of Surrogate/Agent
  • Physical Address of Surrogate/Agent
  • City
  • State
  • Zip Code
  • Telephone number

Step 3 – Alternate Surrogate/Agent – In the event your original selected Surrogate becomes unable or unwilling to provide service you may provide selection of a second person to take over the authorized document if needed (optional) Provide the following information:

  • Name of Alternate Surrogate
  • Physical Address of Successor Attorney-in-Fact
  • City
  • State
  • Zip Code
  • Telephone Number

Step 4 – Enter any additional, detailed, description of the exact powers that will be allowed by the Principal (if more room is needed, add a continued sheet and attach it to the document

Step 5 – Designation Affirmation – In this section, the Principal will provide copies to at least 3 other people besides their surrogate(s) so that it will be known who the surrogate/agent is and how to contact them.

Step 7 – Witness Attestation – In this section two witnesses must sign the document. Lines for both signatures will be located at the end of the document. At least one of the witnesses must unrelated by marriage and may not be a blood relative.

Step 8 – Make copies of the document for your records and the records of all of those who have signed the document on your behalf. You may also need additional copies for physicians and/or medical institutions with whom or where, you may require medical care.