A health care surrogate form is a type of advanced health care directive document which is used by doctors and healthcare agencies for their patients who may have the possibility to be incapacitated due to their medical conditions. With the form, the name of the authorized person who can make decisions for the incapacitated patient will be stated and will be able to be acknowledged by the doctors and legal authorities.

Types of Health Care Surrogate Forms

Below are two of the general types of health care surrogate forms which can be used by doctors, their patients, and any individual who needs to have a document to state the preferred healthcare procedures and agent on the behalf of incapacitation:

Designation of Health Care Surrogate Form – This the type of form to be used if the doctor and the patient have already discussed the details of the surrogate and the authorized person to be designated. The form will indicate the name of the patient along with the names of the authorized surrogates, their contact information, and addresses. In addition, the names of the persons who will be receiving a duplicate for the surrogate form and notification regarding the choices for the designation will also be included as well as the names and signatures of the witnesses who were present during the selection and designation process.

Designation of Health Care Surrogate Form

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Size: 125 KB

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Health Care Proxy Surrogate Form – This form is identical to the aforementioned form type, however, the difference is that it contains more details and has sections which will further explain the choices of the patient for his surrogate decision-maker. There are seven items in a health care proxy surrogate form. The first section contains an appointment statement of the patient which should include the name, address, and phone number of the appointed surrogate. The second section, on the other hand, is for naming the alternate agent if ever the appointed surrogate refuses or declines the appointment. In the third section of the form, the expiration date will be stated while the fourth section is for enlisting the limitations of the surrogate and the agent. The fifth section is for the identification of the patient, while the last two sections are for the patient’s donation preference, and the witness statements and signatures.

Health Care Proxy Surrogate Form

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Size: 257 KB

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How to Get a Health Care Surrogate Form

A health care surrogate form can be obtained from any health care provider and institutions, as well as from online. To obtain the form from the institution, the patient should inform his provider or doctor. On the other hand, if the chosen option is to acquire the form online, then it is important that a blank template will be used. However, when acquiring templates and forms online, the patient or the user must first look out if the form is accompanied by usage and credit regulations. These protect the form and the author or creator which then requires the user to either pay to use, edit, or print the form. Nevertheless, the templates in our site are free to be used and can easily be downloaded without the need to sign up for a subscription. All that’s needed to be done is to choose a variety, click the download button, extract the form from the zip file, and use the form.

Basic Health Care Surrogate Designation Form

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Size: 251 KB

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Tips in Using Our Health Care Surrogate Forms

  • Determine which type is needed: Each type or variety of health care surrogate form in our site differ on its layout, contents, and what it presents to its user.
  • Know the size limitations: The forms in our site also differ in its file sizes. This is why it is essential that the method of using the form will be identified first. For instance, if the form is to be used electronically by sending the form through an email, then it should have a small or light size, while forms which are to be printed out can be of various size ranges. Small or light sized documents can be transmitted and be accessed easily as compared to heavier file sizes that may cause a delay in completing the surrogate designation process.
  • Convert the forms into other formats: There are other formats which can be considered such as “.DOC” and “.XLS” formats. In order to have these formats, the forms must be converted using file converters or software application programs. Each format has its own benefit ranging from accessibility up to ease-of-use.
  • Know the rules and regulations of the State: Each State or country will have different preferences and guidelines which should be met when using any type of health care directive forms such as a health care surrogate form. This is why before using our form templates, the guidelines must first be known and must be listed in a checklist in order to easily review and assess whether or not the form meets the State’s requirements.

Health Care Surrogate Form Sample

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Health Care Surrogate Form FAQs

What is the difference between a medical power of attorney and a health care surrogate?

The difference between a medical power of attorney from a health care surrogate is that an agent for the medical power of attorney could not be appointed by a doctor or a physician while the latter allows a physician to designate a surrogate for his patient. The surrogate can be anyone who is an adult eligible to take on the responsibilities and decisions for the patient’s wellbeing.

Health Care Surrogate with Advanced Directives Form

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Size: 32 KB

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Can the spouse of the patient be a witness who will sign the health care surrogate form?

No. The witness must be an adult who is not related to the patient to avoid having to deal with concerns regarding biased inputs.

Minor Health Care Surrogate Designation Form

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Size: 6 KB

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Regardless of the variety of health care surrogate form which will be used by a patient and his doctor, when appointing an agent, it is important that the adult or the appointee is knowledgeable about the patient’s condition and prior requests. And aside from a health care surrogate form, the patient can also have other health care directives or advanced directive documents that he can present to his doctors such as a living will and an anatomical donation form.

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