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Forms

Click here for
List of 50 memory jogger of documents caregiver may need.
Emergency Medical Information Form to carry with you or put on your refrigerator
Durable POA Sample

Updates to these forms may be avaialbe from the specific agency.
Verify with the agency requesting the form that you are using the right form.

• Common Florida Forms for ACCESS (medicaid)
  ......... (access= Automated Community Connection to Economic Self Sufficiency)
• Do Not Resuscitate Order—Form 1896
  (Multilingual) Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.
  Florida Department of Health 850-245-4444 EMAIL= health@flhealth.gov

• Health Assesment Form 1823 (9-2013)
  ...........Florida Statute require "appropriateness" be determined within 60 days prior or 30 days following admittance.
• FS 429.26Resident Health Assessment for Adult Family Care Homes AHCA Form 3110-1023 AFCH
• Medical Assistance Consent Form.pdf
• Medication Observation Record.pdf
• Menu Plan.pdf
• Resident Agreement Example.pdf
• Resident Observation Log.pdf
• Resident Weight Record.pdf

• Saving Bonds POA

• $500 Property Tax Exemption for Disability

Documents
Caregivers would do well to know the location of these documents.
• Last Will and Testament
• Revocable Living Trust
• Durable Power of Attorney
• Designation of Healthcare Surrogate
• Living Will

Last Will and Testament
•States how your assets will be distributed upon your death.
•Designates who will administer your estate (subject to residency restrictions under Florida law).
•Is executed in accordance with the laws of the State where you reside.
•Is subject to Probate under Florida law, which can cost your estate 5% – 6% or more of its value of the assets in the estate for fees and costs.

Revocable Living Trust
•Can avoid Probate** under Florida law.
•Can avoid probate in other states where you own property.
•States how your assets will be distributed upon your death.
•Designates who will administer your estate (no residency restrictions).
•Allows you to retain full ownership and control over your assets.
•Avoids guardianship by providing for the management of your assets should you become incapacitated or incompetent.
•Can protect a child’s inheritance from his or her creditors, or a soon-to-be ex- spouse.
•Can allow a beneficiary with special needs to have the benefit of an inheritance while continuing to qualify for needs-based government assistance.


Durable Power of Attorney
•Appoints a person to handle your business and financial affairs for you in the event you become incapacitated and unable to act for yourself.
•If created properly, can avoid guardianship proceedings.
•Can be created, but not given to the person chosen, until needed in the future.
•Is a very powerful document. Choose your attorney-in-fact carefully.
•Ends upon your death.
•Should be updated if you have an out-of-state document.

Designation of Healthcare Surrogate
•Appoints a person to make medical decisions for you, such as whether you should receive a certain type of treatment, or undergo an operation, in the event you are unable to make such decisions for yourself.
•Should be updated to include HIPAA language, if existing document pre-dates 2003.

Living Will
•An expression of your wishes that states if you have a terminal condition or end stage condition, with no hope of recovery and if death is imminent, then life- prolonging procedures may be withheld or withdrawn.

**Probate
•Is the process where the court validates your will, gives notice of your death to creditors and other interested parties, and ultimately oversees the distribution of your assets.
•Can cost your estate 5%-6% or more of the value of the assets in the estate.
•Can last many months or longer.