{"data":{"id":"us-fl/fla.-stat.-765.2038","jurisdiction":"us-fl","citation":"Fla. Stat. § 765.2038","heading":"Designation of health care surrogate for a minor; suggested form.","body":"A written designation of a health care surrogate for a minor executed pursuant to this chapter may, but need not, be in the following form:\nDESIGNATION OF HEALTH CARE SURROGATE\nFOR MINOR\nI/We, (name/names) , the [ ] natural guardian(s) as defined in s. 744.301(1), Florida Statutes; [ ] legal custodian(s); [ ] legal guardian(s) [check one] of the following minor(s):\n;\n;\n,\npursuant to s. 765.2035, Florida Statutes, designate the following person to act as my/our surrogate for health care decisions for such minor(s) in the event that I/we am/are not able or reasonably available to provide consent for medical treatment and surgical and diagnostic procedures:\nName: (name)\nAddress: (address)\nZip Code: (zip code)\nPhone: (telephone)\nIf my/our designated health care surrogate for a minor is not willing, able, or reasonably available to perform his or her duties, I/we designate the following person as my/our alternate health care surrogate for a minor:\nName: (name)\nAddress: (address)\nZip Code: (zip code)\nPhone: (telephone)\nI/We authorize and request all physicians, hospitals, or other providers of medical services to follow the instructions of my/our surrogate or alternate surrogate, as the case may be, at any time and under any circumstances whatsoever, with regard to medical treatment and surgical and diagnostic procedures for a minor, provided the medical care and treatment of any minor is on the advice of a licensed physician.\nI/We fully understand that this designation will permit my/our designee to make health care decisions for a minor and to provide, withhold, or withdraw consent on my/our behalf, to apply for public benefits to defray the cost of health care, and to authorize the admission or transfer of a minor to or from a health care facility.\nI/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate:\nName: (name)\nName: (name)\nSigned: (signature)\nDate: (date)\nWITNESSES:\n1. (witness)\n2. (witness)\nHistory.—s. 11, ch. 2015-153; s. 86, ch. 2016-10.","path":["CHAPTER 765 HEALTH CARE ADVANCE DIRECTIVES"],"source_url":"https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute\u0026URL=0700-0799/0765/0765.html","current_through":"2026 Florida Statutes","vintage":"","retrieved_at":"2026-08-27T02:13:57Z","sha256":"37c7e4dd1c304147407ee042a5d558d9bc306baf092c4ed9793f85ef169f3b50","source_id":"us-fl","stale":false,"prev":"us-fl/fla.-stat.-765.2035","next":"us-fl/fla.-stat.-765.204"},"notice":"GroundRules: Original legal text. Not legal advice."}