SAMPLE FORM :
DESIGNATION OF HEALTH CARE SURROGATE
The laws governing health care surrogates may vary from state to state. This form provides a general starting point that you and/or your lawyer may tailor to fit your state’s requirements. It’s also a good idea to carry in your purse or wallet the name and phone number of the surrogate who is to be contacted in the event of an emergency.*
Designation of Health Care Surrogate of:
In the event that I have been determined by health care providers to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I designate as my surrogate for health care decisions:
Name, Address, and Telephone Number of Surrogate:
In the event that my Health Care Surrogate proposes a course of action or medical treatment or procedure, or the removal of the same, which is intended to result in my death (such as, for illustrative purpose, the removal of nutrition and hydration), the following named individuals must give unanimous consent to said proposed decision.
If any one of these named individuals refuses to consent, the action that will result in my death may not be taken.
In the event that my Health Care Surrogate is unable or unwilling to act in said capacity or is determined to have a conflict of interest, whether moral, financial, or any other, by a majority of the following named individuals:
I designate as my alternate surrogate for health care decisions:
Name, Address, and Telephone Number of Alternate Surrogate:
I fully understand that this designation will permit my Health Care Surrogate to make health care decisions for me and to provide, withhold, or withdraw consent to medical procedures on my behalf; to apply for public benefits to defray the cost of health care; to authorize my admission to or transfer from a health care facility; and to have access to medical records pertaining to me and to authorize the release of medical information and medical records to third parties as directed by my Surrogate.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Signed this_________day of _______________, 20_____________.
STATEMENT OF WITNESSES
We declare, under penalty of perjury, that the Declarant is personally known to us, or has produced a driver’s license as identification, that the Declarant signed or acknowledged this Designation of Health Care Surrogate in our presence, that the Declarant appears to be of sound mind and under no duress, fraud, or undue influence, and that we are not the person appointed as Health Care Surrogate by this document or related to the Declarant by blood or marriage.
The foregoing instrument was acknowledged before me this day of , 20 , by , who personally appeared before me at the time of notarization, and who is personally known to me or who has produced a driver’s license as identification and who did take an oath.
* Permission to photocopy granted.