Florida Health Care Surrogate, Living Will and HIPAA Authorization Intake

Florida Health Care Surrogate, Living Will and HIPAA Authorization Intake

This is a Florida Health Care Surrogate, Living Will and HIPAA Authorization document-preparation intake. The document-preparation fee is the flat price quoted to you by Jonathan Rexford, with a 50% deposit due before preparation begins. Your intake is reviewed for completeness, the draft is prepared from the information you provide, and a protected or watermarked PDF draft may be delivered for your review. Legal advice, medical advice, Medicaid advice, and estate-planning advice are not included.
⚠️ Nonlawyer Disclosure & Work Order Agreement

I am not an attorney licensed to practice law in the State of Florida, and I may not give legal advice or accept fees for legal advice. The information and documents provided through this service are based solely on the information you supply.

If you need legal advice, interpretation of the law, or representation in court, you should contact a licensed attorney.

By submitting this form, you acknowledge:

You are requesting document preparation services only.

You understand that no attorney-client relationship is formed.

You are responsible for reviewing your documents for accuracy before signing.

Disclosure from Nonlawyer (Rule 10-2.2(c)(2), Rules Regulating The Florida Bar)

Jonathan Rexford told me that he is a nonlawyer and may not give legal advice, cannot tell me what my rights or remedies are, cannot tell me how to testify in court, and cannot represent me in court.

Rule 10-2.1(h) of the Rules Regulating The Florida Bar defines a paralegal as a person who works under the supervision of a member of The Florida Bar, an out-of-state lawyer engaged in the authorized practice of law in Florida, or a foreign lawyer engaged in the authorized practice of law in Florida and who performs specifically delegated substantive legal work for which the supervising lawyer is responsible. Only persons who meet the definition may call themselves paralegals. Jonathan Rexford informed me that he is not a paralegal as defined by the rule and cannot call himself a paralegal.

Jonathan Rexford told me that he may only type the factual information provided by me in writing into the blanks on the form. Except for typing, Jonathan Rexford may not tell me what to put in the form and may not complete the form for me. However, if using a form approved by the Supreme Court of Florida, Jonathan Rexford may ask me factual questions to fill in the blanks on the form and may also tell me how to file the form.

Every document prepared for you will state that it was completed with the assistance of: Jonathan Rexford, Nonlawyer Document Preparer and Florida Notary Public · 772-321-2290 · jonathan@notarynearmenow.com · www.NotaryNearMeNow.com
Typing-only notice: The document on this intake is not a Florida Supreme Court approved form. Jonathan Rexford may only type the information you give him in writing, exactly as you write it. Please answer every question in your own words. If a question does not apply to you, leave it blank.
- Your full legal name
  
  First NameMiddle NameLast Name
- Other names used (maiden, former, AKA)
- Date of birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Mailing address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email address
  example@example.com
- Which documents do you want prepared?
- Health care surrogate's full legal name
  
  First NameLast Name
- Relationship to you
- Surrogate's address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Surrogate's phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Alternate surrogate's full legal name (optional)
  
  First NameLast Name
- Alternate's relationship, address and phone
- When should your surrogate be able to act?
- Limits or special instructions for your surrogate (optional)
- A Florida living will states whether life-prolonging procedures should be provided, withheld, or withdrawn if you have a terminal condition, an end-stage condition, or are in a persistent vegetative state.
- If I have a terminal condition, life-prolonging procedures should be:
- If I have an end-stage condition, life-prolonging procedures should be:
- If I am in a persistent vegetative state, life-prolonging procedures should be:
- Artificial nutrition and hydration (feeding tube, IV fluids):
- Other wishes, in your own words (optional)
- Organ and tissue donation
- Organs or tissue to donate
- Allow my health care surrogate(s) to see my medical information
- Other people who may see my medical information: full name and relationship
- Limits on what can be shared (optional)
- When should this authorization end?
- End date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Florida requires two adult witnesses. At least one may not be your spouse or a blood relative, and your surrogate may not witness the surrogate designation (s. 765.202, 765.302). Notarization is not required for these documents but is available.
- Will you need Jonathan to notarize your document?
- Optional Add-On Service: Witness coordination for the signing. The witness fee is quoted by Jonathan.
- Witness #1 name (if providing your own)
  
  First NameLast Name
- Witness #1 address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Witness #2 name (if providing your own)
  
  First NameLast Name
- Witness #2 address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Where will the signing take place? (address or city)
- Draft Review, Approval, and Document Retention Policy
  
  Customer acknowledges that all drafts will be emailed as PDF files marked “DRAFT.” All corrections must be requested before giving final approval by email. Final payment is required before receiving completed documents. Working files are kept for 45 days. Copies of your signed disclosure and of all forms given to you are kept for at least 6 years, as Rule 10-2.2(c)(3) of the Rules Regulating The Florida Bar requires.
- I have read and agree to the Draft Review, Approval, and Document Retention Policy.
- Language (choose one)
- If you cannot read English: the language the notice was read to you in
- I have read the Nonlawyer Disclosure & Work Order Agreement above and received a copy of it.
- I understand a 50% deposit is due before preparation begins, with the balance due at completion.
- Price quoted to you by Jonathan Rexford ($)
  Enter the flat price you were quoted.
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: