Florida Medical Power of Attorney
This document is designed to grant authority to an individual to make medical decisions on your behalf in the event that you are unable to do so. This power of attorney is governed by the laws of the State of Florida.
Principal Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip Code: ____________
- Date of Birth: ____________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip Code: ____________
- Phone Number: ____________________
Alternate Agent Information (if applicable):
- Name: ___________________________
- Address: _________________________
- City, State, Zip Code: ____________
- Phone Number: ____________________
Authority Granted:
The agent is authorized to make decisions regarding:
- Medical treatment and procedures.
- Selection of healthcare providers.
- Access to medical records and information.
- End-of-life decisions, including hospice and palliative care.
Effective Date:
This power of attorney shall become effective upon the determination that I am unable to make my own medical decisions.
Revocation:
This document may be revoked at any time by the Principal, provided that the revocation is communicated to the Agent in writing.
Signature:
By signing below, I confirm that I am of sound mind and that I understand the nature and purpose of this Medical Power of Attorney.
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: ______________________ Signature: _______________ Date: ____________
- Witness 2 Name: ______________________ Signature: _______________ Date: ____________
Notary Public:
State of Florida
County of _______________
Subscribed and sworn to before me this ____ day of __________, 20__.
Notary Public Signature: ______________________
My Commission Expires: ______________________