RespiteMatch.com Health Blog

DESIGNATION OF HEALTH CARE SURROGATE

I, ____________________________________, make this a definitive statement of my desires:
If or when it is determined that I am no longer able to give my own informed consent for health care and
medical treatment decisions, I wish to designate the person named below to make and communicate those
decisions for me (health care surrogate):

Name:________________________________________
Address:__________________________________________________________________________________
City _____________________ State_______________ Zip:________________Phone: ___________________
If the person named above is unwilling or unable to make health care and medical treatment decisions for me,
I wish to designate the person named below as my alternate health care surrogate:
Name:________________________________________
Address:__________________________________________________________________________________
City _____________________ State_______________ Zip:________________Phone: ___________________
r I fully understand that this document:
• Permits the person(s) I named above to make health care and medical treatment decisions on my behalf;
• Permits the person(s) I named above to provide, withhold or withdraw consent for health care and medical
treatment on my behalf;
• Permits the person(s) I named above to apply for public financial assistance to help pay for my health care costs;
• Permits the person(s) I named above to authorize my admission to or transfer from a health care facility;
• Excludes organ donation decisions, unless I have filled out an official organ donor form.
Use the space below if you have additional instructions for the health care surrogate:
r I will notify and send a copy of this document to the people named above, and to the following additional
people named below so they will know who my surrogate is.
Name: ___________________________________
Phone ___________________________________
r I am not completing this document as a requirement for treatment or admission to a health care facility.
________________________________ _________________________________ ___________________
My Signature My name (printed) Date
INSTRUCTIONS: Witnesses must be 18 years old or older. The people named as surrogate and alternate surrogates
must not sign this document as witnesses. At least one person who signs as a witness must not be the
spouse or an immediate family member of the person who is completing this document.
Name: ___________________________________
Phone ___________________________________
witness signature witness signature
________________________________________ ____________________________________________
witness name (print) witness name (print)
________________________________________ ____________________________________________
address address
________________________________________ ____________________________________________
phone number phone number