Planning Ahead - Florida Developmental Disabilities Council

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Suggested form of a Health Care Surrogate, Florid Statutes Section 765.203Designation of Health Care SurrogateName __________________________________________________________In the event that I have been determined to be incapacitated to provide informed consent formedical treatment and surgical and diagnostic procedures, I wish to designate, as my surrogatefor health care decisions:Name _____________________________________________Street Address ______________________________________City ________________________ State ______ Zip ________If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as myalternate surrogate:Name ______________________________________________Street Address _______________________________________City _________________________ State ______ Zip ________I fully understand that this designation will permit my designee to make health care decisionsand to provide, withhold, or withdraw consent on my behalf; or apply for public benefits todefray the cost of health care; and to authorize my admission to or transfer from a health carefacility.Additional Instructions (optional):I further affirm that this designation is not being made as a condition of treatment or admissionto a health care facility. I will notify and send a copy of this document to the followingpersons other than my surrogate, so they may know who my surrogate is.Name __________________________________________________________Name __________________________________________________________Signed: _________________________________________________________Witnesses1. ___________________________________2. ___________________________________At least one witness must not be a husband or wife of a blood relative of the principal.~ This form offered as a courtesy of The <strong>Florida</strong> Bar and the <strong>Florida</strong> Medical Association ~86Section 3, Helpful Attachments
My Personal OutcomesWHO AM I?What goals have I set for myself?Where and with whom do I want to live?What do I want to do for my work?Who is closest to me?How satisfied am I with the services and supports I receive?How satisfied am I with my personal life situation?MY SPACEWhat are my preferred daily routines?Do I have the time, space and opportunity for the privacy I need?Am I in control of who knows personal information about me?Do my home, work and other environments support me to do what I want and need to do?MY COMMUNITYDo I have access to the places I want to be?Do I participate in what happens in my community?Am I pleased with the type and extent of my interaction with other people in my community?Am I known for the different social roles I play?Do I have enough friends?Am I respected by others?MY SUCCESSESAre the supports and services I receive the ones I want?Have I realized any of my personal goals?MY SAFEGUARDSAm I connected to the people who support me most?Am I safe?Section 3, Helpful Attachments87
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AcknowledgementsWe would like to th
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SECTION 1THE HANDBOOKDevelopmental
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in realizing goals and outcomes he
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• Identify agencies and organizat
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TO BE SURE YOU HAVE ACCESSED ALL AV
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CHAPTER THREEUsing Government Benef
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Property or assets mean real estate
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There is a special program for peop
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Department of Elder Affairs: The De
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Be sure to complete the application
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Most services provided to persons w
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CHAPTER FIVEAdvocating and Coordina
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family member receives services. De
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• Use the chain of command. If yo
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28ChooseYour family member may make
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7. Skilled Nursing HomeSkilled nurs
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There are now more opportunities fo
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If your family member really thinks
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Page 44 and 45: Can the Living Will and the Health
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Page 48 and 49: The potential ward, if capable of u
Page 50 and 51: LETTERS OF INTENTIn addition to hav
Page 52 and 53: TAX ISSUESIn your planning, do not
Page 54 and 55: CHAPTER TENDealing WithHealth Care
Page 56 and 57: CHAPTER ELEVENCoping with Changes a
Page 58 and 59: • Arrange visits to an area funer
Page 61 and 62: SECTION 2THE PERSONALINFORMATION SU
Page 63 and 64: Senior CenterHomemakerPersonal Care
Page 65 and 66: List relatives who are emotionally
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Page 69 and 70: Do violent or sexually suggestive T
Page 71 and 72: The type of neighborhood preferred
Page 73 and 74: During the day goes to:EMPLOYMENT/R
Page 75 and 76: Provide a brief summary of Medical
Page 77 and 78: Section 2, The Personal Information
Page 79 and 80: The following activity (e.g., being
Page 81 and 82: PROTECTING LEGAL RIGHTS AND FINANCI
Page 83 and 84: Has a standby guardian been appoint
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Page 89 and 90: SECTION 3HELPFUL ATTACHMENTSDevelop
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Page 95 and 96: Bill Of RightsIn June of 1975 the G
Page 97 and 98: Stakeholders requested a change in
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Page 101 and 102: Guardianship To-Do List(Step-by-Ste
Page 103: New York State Developmental Disabi
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Planning Ahead - Florida Developmental Disabilities Council

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