Florida Medical Power of Attorney
This Florida Medical Power of Attorney allows you to designate someone to make medical decisions on your behalf if you become unable to do so. This document is governed by Florida Statutes, Chapter 765.
Principal Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Date of Birth: ______________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Phone Number: ______________________
Designation of Agent:
I, the undersigned Principal, hereby appoint the above-named Agent to act on my behalf in making healthcare decisions for me if I am unable to do so. This authority includes, but is not limited to:
- Making decisions about medical treatment.
- Accessing my medical records.
- Choosing healthcare providers.
Limitations:
My Agent's authority is subject to the following limitations:
______________________________________________________________________
______________________________________________________________________
Effective Date:
This Medical Power of Attorney shall become effective upon my incapacity as determined by my attending physician.
Signature:
______________________________
Principal's Signature
Date: ________________________
Witnesses:
This document must be witnessed by two individuals who are not related to the Principal or the Agent.
- Witness 1 Name: ______________________
- Witness 1 Signature: __________________
- Date: ________________________________
- Witness 2 Name: ______________________
- Witness 2 Signature: __________________
- Date: ________________________________
Notarization:
If desired, this document can also be notarized.
______________________________
Notary Public Signature
Date: ________________________