Florida Health Care Surrogate Designation Template (Word + PDF)

Decide now who speaks for you in the hospital if you can’t.

A Designation of Health Care Surrogate names a competent adult to make health care decisions for you if you cannot make them yourself — or immediately, if you initial the immediate-effect option. This template follows Florida’s suggested form in § 765.203 and includes an alternate surrogate, optional access to health information, and clearly labeled optional schedules.

What’s included

• Health Care Surrogate Designation template
• Alternate surrogate block
• Immediate-effect and health-information initial options
• Optional schedules for specific instructions
• Witness blocks (surrogate may not witness)
• Optional notary block

Signing requirements in Florida

Sign in front of two adult witnesses; the person you name as surrogate cannot be a witness, and at least one witness must be neither your spouse nor a blood relative. No notary is required.

Format and delivery

Fillable Word (.docx) template plus a print-ready PDF for the same document, delivered as an instant download after checkout. Every file includes plain-English completion instructions, a signing checklist, and a “common mistakes” list. Version 1.1 — legal research verified September 15, 2026.

Save with a kit

Included in the Florida Essential Estate Documents Kit, the Healthcare Documents Trio, and the DPOA + Health Care Surrogate Kit.

Rexford Mercantile is not a law firm, and Jonathan and Ruth Rexford are not attorneys. This is a self-help legal template with general instructions — not legal advice, and no attorney–client relationship is created. You are responsible for confirming the form fits your situation and for signing, witnessing, and notarizing it as your state requires. Consult a licensed attorney in your state if your situation involves a blended family, a beneficiary with a disability, out-of-state property, a business, or a family dispute. Digital download with a 30-day satisfaction guarantee — see our Refund Policy. © 2026 Rexford Mercantile. Licensed for the purchaser’s personal use only; not for resale or redistribution.