Florida Medical Power of Attorney
This Medical Power of Attorney is made in accordance with Florida Statutes Chapter 765. It allows you to appoint someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
Name: ________________________________
Address: ________________________________
City, State, Zip: ________________________________
Date of Birth: ________________________________
Agent Information:
Name: ________________________________
Address: ________________________________
City, State, Zip: ________________________________
Phone Number: ________________________________
Alternate Agent (optional):
Name: ________________________________
Address: ________________________________
City, State, Zip: ________________________________
Phone Number: ________________________________
Authority Granted:
I grant my Agent the authority to make decisions regarding my medical care, including but not limited to:
- Choosing healthcare providers
- Making decisions about medical treatments
- Accessing my medical records
- Deciding on life-sustaining treatments
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions.
Signature:
Principal's Signature: ________________________________
Date: ________________________________
Witnesses:
- Witness 1 Name: ________________________________
- Witness 1 Signature: ________________________________
- Witness 2 Name: ________________________________
- Witness 2 Signature: ________________________________
This document must be signed in the presence of two witnesses who are not related to you or your Agent, and who do not stand to benefit from your estate.
It is advisable to keep a copy of this document with your important papers and provide a copy to your Agent and healthcare providers.