Designation Of Health Care Surrogate Form printable pdf download

Designation of Health Care Surrogate

I, ______________________________ (please print) want _________________________________________________________

Print Name

Surrogate’s Name

Phone ____________________________ Address _________________________________________________________________

to be my Health Care Surrogate and make health care decisions for me if I am unable to make these decisions myself. If the above person is unwilling

or unable to make these decisions on my behalf, I want the following alternate:

_________________________________________________________

Alternate Surrogate’s Name

Phone ____________________________ Address _________________________________________________________________

I understand that, unless I note in the “limitations” space provided below, my Health Care Surrogate will be able to:

• Give, or refuse informed consent for my medical care

• Make end of life decisions for me

• Apply for public benefits to help pay for the cost of my care

• Give permission for me to be admitted to or transferred from a health care facility

• Obtain all medical records needed to carry out these duties

• Give permission for the release of information and medical records to provide for my health care

Limitations:

__________________________________________________________________________________________________________________________

I understand that my Health care Surrogate cannot consent to any of the following for me unless I allow him/her to do so by placing my initials in the

space provided.

_______ Abortion

_______ Sterilization

_______ Refusal of life-prolonging procedures if I am pregnant with a fetus that cannot survive outside the womb.

_______ Experimental treatments that have not been approved as research under federal law.

I understand that my Health Care Surrogate cannot admit me to a psychiatric facility, or consent to psychiatric treatment or procedures for me,

without the permission of a court.

I am competent and I understand the importance of this Designation, and sign it in the presence of my two witnesses.

Signature ____________________________________________

Date _____________________________________

Witness ______________________________________________

Print Name

______________________________________________

Signature

Address ______________________________________________

Phone ____________ ___________________________________

Please Note: Only one of the witnesses can be your husband, wife or blood relative. Your surrogate(s) cannot be a witness.

Patient Name:

Patient Identification #:

*AD0001*

AD0001

PS121459

Rev. 10/30/14

Designation Of Health Care Surrogate Form

Related Articles

Related forms

Related Categories