The essential guide to planning for your family s future, with real, useful legal documents to get you started. Health surrogate form

Transcription

1 FREE RESOURCES! ELDER PLANNING PACKET WITH THREE FREE FORMS! The essential guide to planning for your family s future, with real, useful legal documents to get you started. Durable power of attorney form Health surrogate form Living will form NextGenInjuryLaw.com Chapman@NextGenInjuryLaw.com

2 TABLE OF CONTENTS INTRODUCTION... 2 DURABLE POWER OF ATTORNEY... 3 DURABLE POWER OF ATTORNEY FORM..4 HEALTH CARE SURROGATE HEALTH CARE SURROGATE FORM.12 LIVING WILL LIVING WILL FORM... 17

3 INTRODUCTION This is a free Elder Planning packet for Florida residents and is provided by Florida lawyer, Thomas J. Chapman, Esq. of NextGen Injury Law. Please note that supplying this free packet does not establish an attorney-client relationship. If you seek to have a lawyer review and/or assist you in completing these forms, please reach us at NextGen Injury Law and we would be happy to discuss how we may be able to help you in any way. We can also be reached by phone: (561) or Chapman@NextGenInjuryLaw.com

4 DURABLE POWER OF ATTORNEY WHAT IS A DURABLE POWER OF ATTORNEY? A Durable Power of Attorney (DPOA) is a legal document that specifies powers that you are granting to your agent. A Durable Power of Attorney can include transfer of assets and properties, management of finances, as well as medical or legal decisions should you become incapacitated. *Please note: This is not a will. Your power of attorney will expire when you die.* WHO SHOULD I CHOOSE TO BE MY DURABLE POWER OF ATTORNEY? Pursuant to Florida law, you can name any person over the age of 18 years old you choose to act as your agent under a durable power of attorney. It does not necessarily have to be someone in your family. However, if the person is related to you, you must so state in your power of attorney. Make sure the person you choose is trustworthy and will have your best interests in mind. The person you name as your Power of Attorney cannot delegate this responsibility to someone else. HOW LONG DOES MY DURABLE POWER OF ATTORNEY LAST? Unless stated otherwise, your durable power of attorney expires: At the time you die. At the time you revoke the power. HOW DO I FILL OUT THE POWER OF ATTORNEY FORM? Please visit our website, for a step-by-step explanation on how to complete the durable power of attorney form below.

5 DURABLE GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: THAT, I,, presently of (city), Florida, hereinafter referred to as Principal," hereby name, constitute and appoint the Principal's (relationship to Principal),, presently of (city), Florida, if living and able to act, hereinafter referred to as the Agent. NOTICE TO THIRD PARTIES: YOU MUST ACCEPT THIS DURABLE POWER OF ATTORNEY IMMEDIATELY OR FACE POTENTIAL LIABILITY FOR UNREASONABLY REFUSING TO HONOR IT PURSUANT TO FLORIDA STATUTE The Agent shall be the Principal's true and lawful attorney-in- fact to act for and in the Principal's stead, and for Principal's benefit and use, to do all and any of the following things, to wit: 1. To carry on and to transact all of the Principal's business in the State of Florida and in the United States of America; to enter into, perform and carry out, and to rescind, terminate and cancel contracts of all kinds; 2. To buy, take on, lease and otherwise acquire, and to hold, sell, mortgage, hypothecate, pledge, lease and otherwise dispose of and in any and every manner deal with real property, leaseholds and other interest in real property, stocks, bonds, flower bonds, goods, wares, merchandise, choses in action and other property and rights of any nature whatsoever in possession or in action; and to sign, seal, execute, acknowledge and deliver deeds, bills of sale, contracts, agreements, options, leases and other instruments; 3. To transact all of the Principal's ordinary bank and finance business at any of the banks, savings and loan associations or financial institutions in the State of Florida or in the United States of America; to draw checks on said banks; to endorse checks, promissory notes, drafts and bills of exchange for collection or deposit; to waive demand and notice of protest of all such writings; to deposit and withdraw any sum of money from any of the Principal's accounts with said banks, savings and loan associations or financial institutions; initial

6 4. To accept drafts and other negotiable instruments and to receive, endorse, negotiate and deliver bills of lading and other evidences and documents of title to merchandise, stock certificates and other securities; and to borrow money from said banks, savings and loan associations or financial institutions in the State of Florida or in the United States of America, from time to time upon such terms and at such rates of interest as the Agent shall deem proper or expedient, either without security or upon the security of all or any portion or portions of the Principal's property, whether real, personal or mixed; 5. To give, make, sign, seal, execute, acknowledge, and deliver promissory notes and other obligations, mortgages, pledge agreements, hypothecations and other securities and any such mortgage, pledge agreements or hypothecations may be with such powers of sale and/or foreclosure and may contain such other provisions, covenants and conditions as may be deemed necessary or desirable by the Agent; and to execute all documents and writing of whatsoever kind and nature in connection therewith; 6. To collect, receive, enforce payment and collection of and otherwise reduce all sums of money and other kinds of property whatsoever that may be due, payable or belonging to the Principal, to which the Principal may be entitled, or to possession, or which lawfully should belong to the Principal; 7. To remise, release and quitclaim to all my estate, right, title and interest in any property of whatsoever kind or nature; to give, sign, seal, execute and deliver such bonds, guaranty, indemnity or other agreements or undertakings as may be necessary or proper or convenient in connection with any of the transactions hereby authorized; to vote at any and all meetings of stockholders of any corporation on any shares of stock which the Principal may own in such corporation and/ by which the Principal is entitled to vote on any and all questions, elections and other issues that may come before such stockholders' meetings; 8. To exercise and/or claim any and all rights, options and other privileges whatsoever held by the Principal as an insured or as a beneficiary under any policy of insurance whether it be life insurance or any other insurance and to sign such papers as may be necessary in the execution thereof; 9. To prepare, sign, execute/ acknowledge or swear to and to file any and all returns for income and other taxes to the State of Florida and to the United States of America; 10. To prepare, make, execute, swear to or acknowledge any return, information, affidavit or report which may be required by any governmental authority, to pay all taxes, fees, assessments and other similar claims as may become due and to do and perform all things lawfully required of the Principal by authority of law; to make all reports and returns under the Social Security Act; to make charitable and other contributions which the Agent may deem wise; 11. To spend such sums of money for the Principal's family and make advancements to members of the Principal's family for their living expenses, education expenses and other necessary expenses; initial

7 12. To make investments deemed wise by the Agent, including investment in any governmental bonds; 13. To make gifts of any assets to any relative of the Principal (by blood or marriage), including the Agent, provided that the aggregate amount of such gifts to any individual in any calendar year shall not exceed the sum of thirteen thousand dollars ($13,000.00), without the Principal's prior written consent; to exercise or make an elective share and other rights or elections under probate proceedings; 14. To employ domestic servants, companions, nurses or doctors to care for the Principal; to admit the Principal or secure release from any hospital, nursing home or other health care facility; to consent on the Principal's behalf to any treatment or surgical procedure for any injury or disease from which the Principal may be suffering; and to have access to any medical records pertaining to the Principal's physical or mental condition or any communication/ oral or written, from any doctor engaged to treat the Principal. Any doctor engaged to treat the Principal may rely on this Power of Attorney in divulging information as to the Principal's mental or physical condition. As used herein, "doctor" includes physician, surgeon, osteopath, psychologist and other health care professionals; 15. To sign, execute, acknowledge and deliver any deed or other instrument of transfer or conveyance covering personal property or real estate wherever situated to the Trustee or Trustees of any Revocable Trust Agreements created by the Principal by instrument prior to or subsequent to the date of this Power of Attorney which may be amended from time to time; to prepare or arrange for the preparation of and to file all tax returns and pay all taxes required by law, including federal and state returns, and to file all claims for refund or other documents in relation thereto; and to act as Agent in the Principal's place and stead, during the Principal's life, with respect to the Principal's Revocable Trust Agreement, with all authority to act in the Principal's place and with all powers contained herein pursuant to this Durable General Power of Attorney; 16. The Principal hereby gives and grants unto the Agent full power of substitution to appoint and substitute another agent, and any such substitute duly appointed by the Agent shall have the same or more limited powers as herein given within the discretion of the Agent; 17. And generally, without any prejudice to any of the foregoing powers, the Principal hereby gives and grants unto the Agent full power to do any act, thing or deed for and in the Principal's behalf which the Agent may deem wise and proper; 18. Do anything regarding my estate, property and affairs that I could do myself. 19. To create, fund and maintain an Income Trust pursuant to 42 USC 1396(d)(4)(B) in order to qualify me for Medicaid or any other public assistance benefits. 20. To bring forth, file, and execute any lawsuit or cause of action afforded to me under Florida law, including the execution of any contracts for retaining attorneys, settlement of any lawsuit, or any document necessary to complete legal proceedings. initial

8 21. To have access and to be able to obtain all medical records pertaining to the Principal's past or future medical care and treatment, including any communication, oral or written, from any doctor engaged to treat the Principal or who has previously treated the Principal. Any doctor engaged to treat the Principal may rely on this Power of Attorney in divulging information and medical records as to the Principal's mental or physical condition and any medical treatment previously rendered. As used herein, "doctor" includes physician, surgeon, osteopath, psychologist and other health care professionals; 22. To have access at any time or times to any safe deposit box to which I have access, or any safe deposit box rented by me, wheresoever located, and to remove all or any part of the contents thereof; and to surrender or relinquish said safe deposit box; and any institution in which any such safe deposit box may be located shall not incur any liability to me or my estate as a result of permitting my attorney-in-fact to exercise this power. Giving and granting unto the Agent full power and authority to do and perform all and every act and thing whatsoever requisite and necessary to be done in and about the premises, as fully to all intents and purposes as the Principal might or could do if personally present, hereby ratifying and confirming all that the Agent shall lawfully do or cause to be done by virtue of these presents. To induce any third party to act in reliance on the continuing effectiveness and absence of revocation of this instrument, the Principal hereby agrees that any third party receiving a fully executed copy of this instrument (or any other type of copy of this instrument, certified by a Notary Public or any governmental recording clerk to be a true copy either of the original or of an executed copy of this instrument) may rely on the same and on any act of the Agent taken hereunder; and the Principal further agrees that revocation or termination hereof by operation of law or otherwise shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation shall have been received by such third party; and the Principal and the Principal's heirs, executors, personal representatives, legal representatives and assigns, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of such third party having so relied on the provisions of this instrument and its continued effectiveness and absence of revocation. In the event this instrument shall be recorded in any public records, then as to persons relying on such recorded instrument who have no actual notice or knowledge of revocation, the same may only be revoked by an instrument executed in the same manner as this document and also recorded in the same public records, or by the Principal's death or legally declared incompetency. If it becomes necessary for my Agent to hire an attorney to induce any such institutions to rely upon this my duly executed Durable General Power of Attorney, such institution may be subject to attorneys fees and costs for their failure to accept same. initial

9 This Durable General Power of Attorney shall not be affected by Principal's disability, it being Principal's intent that the authority herein conferred shall be exercisable notwithstanding any later incapacity or disability, and all acts done by Agent pursuant to the foregoing powers during any period of disability or incompetence shall have the same effect and inure to Principal's benefit and bind Principal and Principal's heirs, devisees and personal representative as if Principal were competent and not disabled, as provided by Section of the Florida Statutes. If incompetency proceedings are commenced against Principal, Principal nominates the above Power of Attorney, if living and able to act, to be appointed as the guardian of Principal s estate and Principal s person. The terms "Principal" and "Agent" as and when used herein, or any pronouns used in place thereof, shall mean and include the masculine or feminine, the singular or plural number, individuals or corporations and each of their respective successors, heirs, personal representatives and assigns, according to the context thereof. If these presents shall be signed by two or more Principals, all covenants of such parties shall for all purposes be joint and several. (The remaining portion of this page is intentionally left blank) I nitial

10 IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of 20. Sealed and delivered in the presence of: WITNESS SIGNATURE _ Principal Signature WITNESS (print name): _ Principal (print name): Address: WITNESS SIGNTURE WITNESS (print name): STATE OF FLORIDA ) ) SS: COUNTY OF ) NOTARY The foregoing instrument was subscribed, sworn to and acknowledged before me this day of 20 by, who is personally known to me or who has produced her driver's license as identification. IN TESTIMONY WHEREOF I have hereunto subscribed my name and affixed my seal the day and year last above written. NOTARY PUBLIC, State of Florida at Large My commission expires: Printed, typed or stamped name This Document was prepared by: Name: Address: Phone:

11 HEALTH CARE SURROGATE WHAT IS A HEALTH CARE SURROGATE? A health care surrogate makes your medical decisions if you are not able to give informed consent. You must be competent and able to give informed consent when you name your health care surrogate. However, the health care surrogate does not assume responsibilities until such time as you become incapable of making your medical decisions. HOW DO I DESIGNATE A SURROGATE? Your declaration must be in writing, signed by two witnesses, neither of which is the surrogate. Only one witness may be someone who is a spouse or a blood relative. Your named surrogate cannot be a witness. If you cannot physically sign the document, one of your witnesses may sign as they would the living will. A sample form is on the subsequent page. WHO IS ALLOWED TO BE MY SURROGATE? Any adult who is competent. It does not have to be a family member. The surrogate must agree, in writing, to accept the responsibility. This should be done at the time you prepare your surrogate form, if possible. WHAT CAN MY HEALTH CARE SURROGATE DO? Review your medical records. Consult with your health care providers. Give medical consent. If you have made your health care decisions known to your surrogate, your surrogate must carry them out as permitted by Florida law. If you have not made your decisions known, then your surrogate will try to make decisions in your best interest. Apply for medical benefits on your behalf. Obtain release of medical information. Exercise such other rights as set out in Florida Law. CREATING A VALID SURROGATE FORM: Sign the document in front of two witnesses. The party designated as a surrogate or alternate cannot be the witness and at least one person who acts as a witness shall be neither your spouse nor blood relative. Give a copy of the designation form to all of your health care providers. Keep the original in a safe place.

12 The surrogate must agree, in writing, to accept the responsibility. This should be done at the time you prepare your surrogate form, if possible. The designation can be voided by designating a new health care surrogate or by clearly revoking it. However, the new health care surrogate designation or the revocation may not become effective unless communicated to all of your health care providers.

13 DESIGNATION OF HEALTH CARE SURROGATE I,, designate as my health care surrogate under s , Florida Statutes: Name: Address: Phone: If my health care surrogate is not willing, able, or reasonably available to perform his or her duties, I designate as my alternate health care surrogate: Name: Address: Phone: INSTRUCTIONS FOR HEALTH CARE I authorize my health care surrogate to: (Initial here) Receive any of my health information, whether oral or recorded in any form or medium, that: 1. Is created or received by a health care provider, health care facility, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and 2. Relates to my past, present, or future physical or mental health or condition; the provision of health care to me; or the past, present, or future payment for the provision of health care to me. I further authorize my health care surrogate to: (Initial here) Make all health care decisions for me, which means he or she has the authority to: 1. Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care, including life-prolonging procedures. 2. Apply on my behalf for private, public, government, or veterans benefits to defray the cost of health care. 3. Access my health information reasonably necessary for the health care surrogate to make decisions involving my health care and to apply for benefits for me. 4. Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes. (Initial here) Specific instructions and restrictions: While I have decision making capacity, my wishes are controlling and my physicians and health care providers must clearly communicate to me the treatment plan or any change to the treatment plan prior to its implementation.

14 To the extent I am capable of understanding, my health care surrogate shall keep me reasonably informed of all decisions that he or she has made on my behalf and matters concerning me. THIS HEALTH CARE SURROGATE DESIGNATION IS NOT AFFECTED BY MY SUBSEQUENT INCAPACITY EXCEPT AS PROVIDED IN CHAPTER 765, FLORIDA STATUTES. PURSUANT TO SECTION , FLORIDA STATUTES, I UNDERSTAND THAT I MAY, AT ANY TIME WHILE I RETAIN MY CAPACITY, REVOKE OR AMEND THIS DESIGNATION BY: (1) SIGNING A WRITTEN AND DATED INSTRUMENT WHICH EXPRESSES MY INTENT TO AMEND OR REVOKE THIS DESIGNATION; (2) PHYSICALLY DESTROYING THIS DESIGNATION THROUGH MY OWN ACTION OR BY THAT OF ANOTHER PERSON IN MY PRESENCE AND UNDER MY DIRECTION; (3) VERBALLY EXPRESSING MY INTENTION TO AMEND OR REVOKE THIS DESIGNATION; OR (4) SIGNING A NEW DESIGNATION THAT IS MATERIALLY DIFFERENT FROM THIS DESIGNATION. MY HEALTH CARE SURROGATE S AUTHORITY BECOMES EFFECTIVE WHEN MY PRIMARY PHYSICIAN DETERMINES THAT I AM UNABLE TO MAKE MY OWN HEALTH CARE DECISIONS UNLESS I INITIAL EITHER OR BOTH OF THE FOLLOWING BOXES: IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE S AUTHORITY TO RECEIVE MY HEALTH INFORMATION TAKES EFFECT IMMEDIATELY. IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE S AUTHORITY TO MAKE HEALTH CARE DECISIONS FOR ME TAKES EFFECT IMMEDIATELY. PURSUANT TO SECTION (3), FLORIDA STATUTES, ANY INSTRUCTIONS OR HEALTH CARE DECISIONS I MAKE, EITHER VERBALLY OR IN WRITING, WHILE I POSSESS CAPACITY SHALL SUPERSEDE ANY INSTRUCTIONS OR HEALTH CARE DECISIONS MADE BY MY SURROGATE THAT ARE IN MATERIAL CONFLICT WITH THOSE MADE BY ME. (The remaining portion of this page is intentionally left blank)

15 IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of 20. Sealed and delivered in the presence of: WITNESS SIGNATURE _ Principal Signature WITNESS (print name): _ Principal (print name): Address: WITNESS SIGNTURE WITNESS (print name): STATE OF FLORIDA ) ) SS: COUNTY OF ) NOTARY The foregoing instrument was subscribed, sworn to and acknowledged before me this day of 20 by, who is personally known to me or who has produced her driver's license as identification. IN TESTIMONY WHEREOF I have hereunto subscribed my name and affixed my seal the day and year last above written. NOTARY PUBLIC, State of Florida at Large My commission expires: Printed, typed or stamped name This Document was prepared by: Name: Address: Phone:

16 LIVING WILL This document will control your medical treatment options if you are on life support. Here are some definitions of terms used in the Living Will: END-STAGE CONDITION means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and for which, to a reasonable degree of medical probability, treatment of the condition would be ineffective. TERMINAL CONDITION means a condition caused by injury, disease or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death. PERSISTENT VEGETATIVE STATE means a permanent and irreversible condition of unconsciousness in which there is (a) the absence of voluntary action or cognitive behavior of any kind and (b) an inability to communicate or interact purposefully with the environment. LIFE-PROLONGING PROCEDURE means any medical procedure, treatment or intervention, including artificially provided sustenance and hydration, which sustains, restores or supplants a spontaneous vital function. The term does not include the administration of medication or performance of a medical procedure(s), when such medication or procedure(s) is deemed necessary to provide comfort, care, or to alleviate pain. CREATING A VALID LIVING WILL: The principal must sign the document in front of two witnesses, one of whom is neither a spouse nor a blood relative of the principal. If the principal is physically unable to sign the living will, one of the witnesses must subscribe the principal s signature in the principal s presence and at the principal s direction. The principal is responsible for notifying his or her primary physician that a living will has been made. In the event the principal is physically or mentally incapacitated at the time the principal is admitted to a health care facility, any other person may notify the physician or health care facility of the existence of the living will. A primary physician or health care facility which is so notified shall promptly make the living will or a copy thereof a part of the principal s medical records.

17 LIVING WILL Declaration made this day of,, (day) (month) (year) I,, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that: If at any time I am incapacitated and (INITIAL ALL THAT APPLY) I have a terminal condition, or I have an end-stage condition, or I am in a persistent vegetative state and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain. ADDITIONAL INSTRUCTIONS (optional): It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

18 In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration: Name: Address: Phone: I, understand the full impact of this declaration, and I am emotionally and mentally competent to make this declaration. I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility. Principal Signature: Address: Phone: Witness 1 Name: Witness 1 Signature: Address: Phone: Witness 2 Name: Witness 2 Signature: Address: Phone: