Florida Living Will Declaration Template And Health Care Surrogate (Page 2 of 2) in pdf

Florida Living Will Declaration Template And Health Care Surrogate Page 2

I understand the full import of this declaration, and I am emotionally and mentally

competent to make this declaration. I designate my health care surrogate as my personal

representative under 45 CFR § 164.504(g), a portion of the regulations implementing the

Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA"), for

all health care-related decisions.

______________________________

Declarant’s Signature

________________________________

# 1 Witness Signature

# 2 Witness Signature

________________________________

Address

Before me, on this ____ day of _________ 20___ , personally appeared :

Declarant

whose I.D. is

#1 Witness______________________ whose I.D. is

#2 Witness______________________ whose I.D. is

to be the Declarant and Witnesses, respectfully, whose names are signed to the forgoing

instrument, and who, in the presence of each other, did freely subscribe their names to the

Declaration (Living Will) on this date, and that each was over the age of majority and of

sound mind.

____________________________________ My Commission Expires:

Notary Public

DISCLAIMER: The law allows you to complete advance directives without the assistance of legal counsel.

America Living Will Registry provides these advance directive forms as a service to you and does not take

responsibility for the manner in which you complete them. If you have any questions about any part of these

advance directive forms, be sure to consult an attorney before you sign them.

America Living Will Registry, LLC, 2814 Beach Boulevard South, St. Petersburg, FL 33707

1-866-305-ALWR

web site:

e-mail:

Florida Living Will Declaration Template And Health Care Surrogate Page 2