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Health Care Surrogate Worksheet PATIENT 'S NAME: DOB: Directions: This form is used to specify the type of surrogate who is allowed to make health care decisions for the above patient when s/he is.

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These include: Living Will. A living will is a written document that specifies what medical treatment you would or would not want in the event you are in a terminal condition or a persistent vegetative state. ... Power of Attorney. ... Health Care Instructions.

Proxy: a designated individual legally empowered to make decisions related to the health care of an individual (the “declarant”) in the event that he or she is unable to do so; also known as agent and surrogate.

A surrogate decision maker, also known as a health care proxy or as agents, is an advocate for incompetent patients. If a patient is unable to make decisions for themselves about personal care, some agent must make decisions for them.

Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. The two most common advance directives for health care are the living will and the durable power of attorney for health care.

A Health Care Proxy is also known as a Health Care Surrogate, Agent, Attorney-in-Fact or other similar terms. Here, we'll use the terms Healthcare Surrogate, Proxy and Agent interchangeably. A Health Care Proxy makes medical decisions for you if you can't make them on your own for any reason.

A person may orally designate a surrogate to make healthcare decisions only by personally informing the supervising healthcare provider (SHCP, see definitions). This appointment is only effective during the course of treatment, illness, or stay in the healthcare institution (usually 60 days or less).

A "health care proxy," sometimes called a "health care surrogate" or "durable medical power of attorney," is a durable power of attorney specifically designed to cover medical treatment.

What is a health care agent? A health care agent (also known as surrogate decision-maker or or proxy decision-maker) is the person you choose to make decisions about medical care on your behalf. Your agent is someone who would speak for you if you were unable to make or communicate your own wishes for health care.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232