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Designation of Health Care Surrogate Questionnaire

Living Will Documents authorize person(s) who are your agents to carry out your wishes in the event you are unable to communicate your decisions to extend, withhold or withdraw life-prolonging procedures under certain legally-permissible circumstances.

Designation of Health Care Surrogate is a Document in which you authorize someone to make health care decsions on your behalf.

HIPAA Release is a document where you authorize the release of limited private medical information so that an agent can make informed decisions on your behalf.

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Contact Information:

Please Provide your contact information:

Name:* Address: City: State: Zip: County: Phone: CELL: Email:

Legal Names:

List any prior legal names, nicknames, or maiden names:

Name 1: Name 2: Name 3:

Health Care Information:

Your Health Care Surrogate is the person you designate to make decisions on your behalf in the event you are unable.

Health Care Surrogate:

Name: Address: City: State: Zip: Home Phone: CELL:

Alternate Health Care Information:

In the event your Health Care Surrogate is unable to or unwilling to make decisions on your behalf, who would you like to designate as your

Alternate Health Care Surrogate:

Name: Address: City: State: Zip: Home Phone: CELL:

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.