Florida Medical Power Of Attorney

Information you will need

• Principal Name
• Alternate Health Care Surrogate Name
• Alternate Health Care Surrogate Address
• Alternate Health Care Surrogate Address Phone Number
• Health Care Surrogate Name
• Health Care Surrogate Address
• Health Care Surrogate Phone Number
• Specific Instructions and Restrictions
• Principal Signature Date
• Principal Address
• Principal City and State
• First Witness Name City and State
• First Witness Signature Date
• Second Witness Name
• Second Witness Address
• Second Witness Name City and State
• Second Witness Signature Date
• First Witness Name
• First Witness Address
• Receive Health Information
• Make All Health Care Decisions
• Make an Anatomical Gift
• Immediate Authority to Receive Health Information
• Immediate Authority to Make Health Care Decisions

Completed by the provider.

The form includes 3 signature lines, a witness section.