Free Florida Living will combo by 1pqb6Z

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									WARNING: These documents were prepared for a client of mine in March 2008. I am
providing them to the public in the effort to ensure that everyone can afford to have a living
will and not make themselves or their families suffer needlessly. Terri Schievo is a house hold
name and only because she did not have a document like this in place at the time of her injury.
 Statutes and laws change regularly. It is possible that you could be reading this document
after a change in the law. We are forming no attorney client privilege and strongly suggest
that you have these documents reviewed by an attorney for accuracy and compliance with the
laws then in effect at the time. Laws do change on a regular basis and you should have any
power of attorney or medical power of attorney reviewed on a regular basis. If you do not
understand these documents there are many sources for information on the Internet. You
should never sign a document without reading and understanding what you are reading.

                                           May 19, 2012


       Re:     Combination Living Will and Designation of Health Care Surrogates


Dear __________________:

       I have enclosed unsigned originals of the following documents:

       (1)     Instructions to execute documents
       (2)     Answers to Frequently asked questions. (in this letter)
       (3)     Combination Living Will and Designation of Health Care Surrogates and
               HIPPA Release

        Instructions have been enclosed with this letter which will enable you to execute your
documents without the need to come to my office. It is very important that you follow the
instructions carefully. A document may be declared invalid if it is not signed, witnessed and/or
notarized properly. If you would like your documents reviewed for accuracy, I will review and yor
estate planning needs free of charge if you send in a completed estate planning questionnaire with a
copy of your signed documents. Once I have reviewed the documents I will send you a digital copy
so that you can print or email as many copies as you need.

             Combination Living Will and Designation of Health Care Surrogates

        The Combination Living Will and Designation of Health Care Surrogates allows the
designated person or persons to consent to medical care on your behalf should you suffer an injury or
become mentally disabled. The Combination Living Will and Designation of Health Care Surrogates
is designed to become effective if you are unable to make health care decisions and that fact is
certified in writing by a physician. The appointed agent may consent, refuse to consent, or withdraw
consent to medical treatment and may make decisions about withdrawing or withholding
life-sustaining treatment. Your agent's authority begins when your physician certifies that you no
longer have the capacity to make health care decisions. Unless stated otherwise, your agent has the
same authority to make decisions about your health care as you would have had. Furthermore, and
importantly, the form serves as your statement that you do not want your life to be artificially
prolonged in certain circumstances. In the document, it is possible to direct the timing of when
certain medical treatments will be suspended.



                                          HIPAA Release

        I have included a HIPAA Release in your document. The HIPAA Release allows the
designated person or persons to obtain all medical information about you. This form is designed to
negate a new privacy law, known as the Health Insurance Portability and Accountability Act, which
makes it difficult for anyone other than you to obtain this type of information. Without a HIPAA
release your agent would not be able to obtain medical information that might be necessary to make
medical decisions on your behalf.

       Please read the entire document and pay careful attention to the definitions for the choices on
page 1 of the Living will. I have enclosed a copy of 2, 10 & 14 for your review. I have also made
them bold in the definitions part of the document on page 3-4.

        2.       "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 which,
to a reasonable degree of medical probability, treatment of the condition would be ineffective.

      10.    "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.
             b.      An inability to communicate or interact purposefully with the environment.

       14.     "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.


       If you do not understand the document or you would like my office to prepare and review the
document on your behalf you may contact me for more information. As this is a document that I am
providing at no charge, I will be unable to make revisions, or provide individual help in execution for
those of you who are not my clients. I hope you find this document useful.

                                                       Very truly yours,



                                                       David Goldman
Enclosures
                       INSTRUCTIONS TO EXECUTE DOCUMENTS


      These instructions are designed to enable you to execute your document(s) without the need
to come to my office. You should follow the instructions carefully when executing your
document(s).


Combination Living Will and Designation of Health Care Surrogates:

Living Will: This document needs to be initialed on page one as deemed appropriate, and then
signed and witnessed. A common mistake is to use an “X” or Check mark where the choices are.
You should initial any choices you desire to be effective.
       You need to sign this document and have it witnessed by two competent adult witnesses.
Neither witness can be the person appointed as agent. Neither witness can be related to you by blood
or marriage. A notary is required only if an acknowledgment has been added to the document.


        If you would desire an attorney to review these documents you may forward me a copy
with an estate planning check list and I will review all the materials at no charge.
I will make certain that the document(s) have been executed properly, and email you a digital copy
of the documents so that you can email and print as many copies as you desire.

        The estate planning documents can be downloaded by visiting the
http://www.FloridaEstatePlanningLawyerBlog.com and searching for Questionnaire or the following
link http://www.floridaestateplanninglawyerblog.com/florida_estate_planning_questionnaire.doc




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                           COMBINATION LIVING WILL
                                     AND
                    DESIGNATION OF HEALTH CARE SURROGATE
                      (AND HIPAA RELEASE AUTHORIZATION)


       I, _____________________________ of ______________ County, Florida, willfully and
voluntarily make this Living Will and Designation of Health Care Surrogate, and I do hereby declare:

                       Statement Regarding Life Sustaining Procedures

       I desire to 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 both mentally and
physically incapacitated and

       ______          I have a terminal condition,

or     ______          I have an end-stage condition,

or       ______        I am in a persistent vegetative state
(Initial your choices above)

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. It is my intention that this declaration be honored
by my family and physicians as the final expression of my legal right to refuse medical or surgical
treatment and to accept the consequences of such refusal. I understand the full import of this
directive and I am emotionally and mentally competent to make this directive.

                             Designation of Health Care Surrogate

        In the event that I have been determined to be incapacitated to provide informed consent for
medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for
health care decisions:

         Name:                 __________________________________________
         Address:              __________________________________________
         Phone:                __________________________________________

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The determination of whether I have become incapacitated to provide informed consent for medical
treatment and surgical and diagnostic procedures shall be certified in writing by my physician.

                                       Alternate Surrogate

       If my surrogate is unwilling or unable to perform his or her duties, I wish to designate the
following person as my surrogate to make health care decisions for me as authorized by this
document:

          Name:                __________________________________________
          Address:             __________________________________________
          Phone:               __________________________________________




                                      Additional Instructions

        My surrogate shall have full power and authority to make all health care decisions for me
during my incapacity as if I were able to make such decisions myself. In particular, and without
limiting my surrogate's authority, my surrogate shall have the following powers:

       1.     The power to consult expeditiously with appropriate health care providers to provide
informed consent, including written consent on an appropriate form, to any medical procedure;

      2.     The power to make health care decisions for me which my surrogate believes I would
have made under the circumstances if I were capable of making such decisions;

        3.      The power to apply for public benefits, such as Medicare and Medicaid, for me, and
to have access to information regarding my income, assets, banking records, and financial records as
required to make such application;

       4.      The power to authorize the release of information and clinical records to appropriate
persons to ensure the continuity of my health care; and

         5.    The power to authorize the transfer and admission of me to or from a health care
facility.

                                            Definitions

        The following definitions as set forth in Section 765.101 of the Florida Statutes shall apply:

                                                  2
       1.      "Attending physician" means the primary physician who has responsibility for the
treatment and care of the patient.

        2.       "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 which,
to a reasonable degree of medical probability, treatment of the condition would be ineffective.

       3.      "Health care decision" means:

               a.      Informed consent, refusal of consent, or withdrawal of consent to any and all
               health care, including life-prolonging procedures and mental health treatment, unless
               otherwise stated in the advance directives.

               b.      The decision to apply for private, public, government, or veterans' benefits to
               defray the cost of health care.

               c.      The right of access to all records of the principal reasonably necessary for a
               health care surrogate to make decisions involving health care and to apply for
               benefits.

               d.      The decision to make an anatomical gift pursuant to part V of chapter 765 of
               the Florida Statutes.

        4.     "Health care facility" means a hospital, nursing home, hospice, home health agency,
or health maintenance organization licensed in this state, or any facility subject to part I of chapter
394.

        5.     "Health care provider" or "provider" means any person licensed, certified, or
otherwise authorized by law to administer health care in the ordinary course of business or practice
of a profession.

         6.     "Incapacity" or "incompetent" means the patient is physically or mentally unable to
communicate a willful and knowing health care decision. For the purposes of making an anatomical
gift, the term also includes a patient who is deceased.

       7.       "Informed consent" means consent voluntarily given by a person after a sufficient
explanation and disclosure of the subject matter involved to enable that person to have a general
understanding of the treatment or procedure and the medically acceptable alternatives, including the
substantial risks and hazards inherent in the proposed treatment or procedures, and to make a
knowing health care decision without coercion or undue influence.

       8.      "Life-prolonging procedure" means any medical procedure, treatment, or intervention,

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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 medical procedure, when such medication or procedure is deemed necessary to
provide comfort care or to alleviate pain.

       9.      "Living will" or "declaration" means:

               a.     A witnessed document in writing, voluntarily executed by the principal in
               accordance with Florida Statute 765.302; or

               b.      A witnessed oral statement made by the principal expressing the principal's
               instructions concerning life-prolonging procedures.

      10.    "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.

               b.      An inability to communicate or interact purposefully with the environment.

       11.     "Physician" means a person licensed pursuant to chapter 458 or chapter 459 of the
Florida Statutes.

        12.    "Principal" means a competent adult executing an advance directive and on whose
behalf health care decisions are to be made.

        13.    "Surrogate" means any competent adult expressly designated by a principal to make
health care decisions on behalf of the principal upon the principal's incapacity.

       14.     "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.

                                    HIPAA Release Authority

        I intend for my surrogate to be treated as I would be treated with respect to my rights
regarding the use and disclosure of my individually identifiable health information and other medical
records. This release authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164. This
release authority is effective immediately.

       Accordingly, I hereby authorize any doctor, physician, medical specialist, psychiatrist,
chiropractor, health-care professional, dentist, optometrist, health plan, hospital, hospice, clinic,

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laboratory, pharmacy or pharmacy benefit manager, medical facility, pathologist, or other provider of
medical or mental health care, as well as any insurance company and the Medical Information
Bureau Inc. or other health-care clearinghouse that has paid for or is seeking payment from me for
such services, to give, disclose and release to my surrogate who is named herein and who is currently
serving as such, without restriction, all of my individually identifiable health information and
medical records regarding any past, present or future medical or mental health condition, including
all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases,
mental illness, and drug or alcohol abuse. Additionally, my surrogate shall have the ability to ask
questions and discuss my protected medical information with the person or entity who has possession
of the protected medical information even if I am fully competent to ask questions and discuss this
matter at the time. It is my intention to give a full authorization to any protected medical information
to my surrogate. Such information may also be released to any person designated as a primary or
successor agent or attorney-in-fact in a durable power of attorney which I have executed, whether or
not such person is presently serving as such, and to any person presently serving as trustee or named
as a successor trustee in any revocable or irrevocable trust created by me as settlor.

        In determining whether I am incapacitated, all individually identifiable health information
and medical records shall be released to the person who is nominated as my surrogate hereunder,
including any written opinion relating to my incapacity that the person nominated as my surrogate
may have requested. This release authority applies to any information governed by HIPAA and
applies even if that person has not yet begun serving as my surrogate.

        This authority given to my surrogate shall supersede any prior agreement that I may have
made with my health-care providers to restrict access to or disclosure of my individually identifiable
health information. The individually identifiable health information and other medical records given,
disclosed, or released to my surrogate may be subject to redisclosure by my surrogate and may no
longer be protected by HIPAA. The authority given to my surrogate herein has no expiration date
and shall expire only in the event that I revoke this Combination Living Will and Designation of
Health Care Surrogate in writing and deliver it to my health-care provider. There are no exceptions
to my right to revoke this Combination Living Will and Designation of Health Care Surrogate.

                                              Duration

        My designation of a health care surrogate shall exist indefinitely from the date I execute this
document unless I establish a shorter time or revoke such designation. However, if I do establish a
shorter time for the existence of my designation and if I am unable to make health care decisions for
myself when this designation of a health care surrogate does expire, the authority I have granted my
surrogate shall, nevertheless, continue to exist until the time I become able to make health care
decisions for myself.




                                                   5
                                   Prior Designations Revoked

       I revoke any prior Designation of Health Care Surrogate or similar document.

        I fully understand that this designation of a health care surrogate will permit my designee to
make health care decisions and to provide, withhold, or withdraw consent on my behalf; to apply for
public benefits to defray the cost of health care; and to authorize my admission to or transfer from a
health care facility.

       I further affirm that this designation of a health care surrogate is not being made as a
condition of treatment or admission to a health care facility. I will notify and send a copy of this
document to the following persons other than my surrogate, so they may know who my surrogate is.

       Name:           _____________________________

       Name:           _____________________________

      This Living Will and Designation of Health Care Surrogate is made on
_________________________, _______, at ______________ County, Florida.




                                               _____________________________, Principal



SIGNATURE OF FIRST WITNESS

       The Principal signed the foregoing Living Will and Designation of Health Care Surrogate in
my presence. I am not a person appointed as surrogate by this document. I am an adult, and I am not
the spouse nor a blood relative of _____________________________.

         Witness Signature:
         Print Name:
         Address:
         Phone:
         Date:                                                            , _______



                                                  6
SIGNATURE OF SECOND WITNESS

       The Principal signed the foregoing Living Will and Designation of Health Care Surrogate in
my presence. I am not a person appointed as surrogate by this document. I am an adult, and I am not
the spouse nor a blood relative of _____________________________.

        Witness Signature:
        Print Name:
        Address:
        Phone:
        Date:                                                           , _______




THE STATE OF FLORIDA                        §
                                            §
COUNTY OF ______________                    §

              Before me, the undersigned authority, on this day personally appeared
_____________________________, who is personally known to me or who has produced
____________________________ (type of identification) as identification proving him to be the
person whose name is subscribed to the foregoing instrument as Principal,
_________________________, a witness who is personally known to me or who has produced
____________________________ (type of identification) as identification, and
_________________________, a witness who is personally known to me or who has produced
____________________________ (type of identification) as identification, each of whom
acknowledged to me that such Principal executed the foregoing instrument in the presence of such
witnesses, who signed as witnesses, for the purposes and consideration therein expressed.

                Given under my hand and seal of office, on _________________________, _______.



                                             Notary Public, State of Florida

                                             Notary's printed name:



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