Healthcare Surrogate Designation Form
Designation of a healthcare surrogate to make medical decisions if you become unable — distinct from a durable healthcare power of attorney; lighter-weight, immediate, and revocable.
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HEALTHCARE SURROGATE DESIGNATION
Governing state: Oregon
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1. PRINCIPAL (PERSON DESIGNATING THE SURROGATE)
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Name: Jordan Alex Taylor
Date of birth: June 12, 1985
Address: 482 Elm Street, Apt 3B, Portland, OR 97214
Phone: +1 503 555 0118
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2. PRIMARY HEALTHCARE SURROGATE
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I, the principal named above, designate the following person as my
Healthcare Surrogate to make healthcare decisions on my behalf:
Name: Sam Devon Taylor
Relationship: Sister
Address: 88 Pine Lane, Portland, OR 97214
Phone (24/7): +1 503 555 0142
Email: sam.taylor@example.com
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3. ALTERNATE HEALTHCARE SURROGATE
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If my primary surrogate is unwilling, unable, or unavailable to act,
I designate the following alternate:
Name: Casey Renee Brooks
Relationship: Close friend (15 years)
Address: 1422 SE Belmont St, Portland, OR 97214
Phone: +1 503 555 0177
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4. WHEN AUTHORITY BECOMES EFFECTIVE
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When attending physician determines I lack capacity
If the trigger is determination of incapacity by the attending
physician: my surrogate's authority begins when my attending
physician documents in my medical record that I lack capacity to
make my own healthcare decisions. The authority ends when I regain
capacity (by physician determination).
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5. SCOPE OF AUTHORITY
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Scope: Full healthcare decisions including end-of-life
My surrogate is authorized, within the scope above, to:
(a) Consent to or refuse any medical examination, test, or
procedure;
(b) Consent to or refuse any medication or course of treatment;
(c) Consent to or refuse hospital admission, transfer, or discharge;
(d) Consent to or refuse mental health treatment to the extent
permitted by state law (additional protections may apply for
inpatient psychiatric admission);
(e) Hire, supervise, or terminate healthcare providers;
(f) Access my medical records under HIPAA (see Section 7);
(g) Make decisions about life-sustaining treatment, consistent with
my advance directive if I have one and with the limitations
below;
(h) Authorize organ and tissue donation consistent with my
pre-existing registration or wishes;
(i) Make funeral and disposition arrangements per state law if no
other instructions exist.
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6. SPECIFIC LIMITATIONS AND INSTRUCTIONS
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I direct my surrogate to honor the following:
• Aggressive pain management is preferred over preserving alertness in late-stage illness.
• I prefer hospice over hospital admission once curative treatment is no longer effective.
• I do not want artificial nutrition or hydration if I am in a permanent vegetative state.
• I have donated organ status; honor my organ donor registration.
(Modify or strike as appropriate.)
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7. HIPAA AUTHORIZATION FOR SURROGATE
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PHI access: Yes — surrogate may access all PHI as needed to make decisions
I authorize my surrogate to receive and review my Protected Health
Information (PHI) under HIPAA (45 CFR Part 164) to the extent
indicated above. This authorization includes communicating with my
healthcare providers, reviewing my medical records, receiving
laboratory and imaging results, and discussing my care.
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8. RELATIONSHIP TO OTHER DOCUMENTS
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This designation is intended to be CONSISTENT with any advance
directive, healthcare power of attorney, living will, POLST, or
similar document I have signed. If a conflict exists:
• If I have a durable healthcare power of attorney, that document
controls and this designation is supplementary or supersedes only
where this document is later in time and explicit.
• My living will or advance directive controls on the substantive
questions of treatment preference; this designation governs WHO
decides.
• A POLST signed by my clinician translates these preferences into
actionable medical orders for current serious illness.
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9. RIGHT TO REVOKE
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I may revoke this designation at any time by:
(a) Signing a written revocation;
(b) Signing a new healthcare surrogate designation that supersedes
this one;
(c) Verbally revoking in the presence of two witnesses or my
attending physician (effective when documented in my medical
record);
(d) Destroying or canceling this document with intent to revoke.
I should provide notice of revocation to my prior surrogate, my
healthcare providers, and any institution where this document is on
file.
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10. PRINCIPAL SIGNATURE
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I, Jordan Alex Taylor, sign this Healthcare Surrogate
Designation freely and voluntarily.
_____________________________________ May 11, 2026
Principal signature Date
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11. WITNESS / NOTARIZATION
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Execution method: Two witnesses (no notary required)
WITNESSES (each witness must NOT be: the designated surrogate or
alternate; a healthcare provider treating the principal; an employee
of such provider; or, in some states, an heir or beneficiary of the
principal's estate. Witness must be at least 18 years old.)
We, the undersigned, witness that the principal signed this document
in our presence, appeared to be of sound mind and acting voluntarily,
and is personally known to us or provided satisfactory identification.
_____________________________________ May 11, 2026
Witness 1 — signature Date
Printed name: Michelle Adebayo
Address: 622 SE Salmon St, Portland, OR 97214
_____________________________________ May 11, 2026
Witness 2 — signature Date
Printed name: Daniel Park
Address: 305 NW 13th Ave, Portland, OR 97209
NOTARY ACKNOWLEDGEMENT (where required or recommended)
State of __________________
County of _________________
On May 11, 2026 before me personally appeared
Jordan Alex Taylor, who proved to me on the basis of
satisfactory evidence to be the person whose name is subscribed to
the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their authorized capacity, and that by
his/her/their signature on the instrument the person executed the
instrument.
_____________________________________ [SEAL]
Notary Public
My commission expires: _____________
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COPIES TO: PRINCIPAL, SURROGATE, ALTERNATE, PRIMARY CARE PROVIDER,
ATTORNEY (IF ANY), STATE REGISTRY (IF AVAILABLE)
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About this template
A Healthcare Surrogate Designation is a focused, lightweight legal instrument that designates a person to make medical decisions for you if you become unable to make them yourself. It is closely related to — but legally and practically distinct from — a durable healthcare power of attorney (HPOA). The differences matter: (1) Scope. An HPOA is typically a comprehensive legal document, often part of a broader estate-planning package, that grants durable authority over many aspects of healthcare and may include detailed treatment preferences. A healthcare surrogate designation is narrower and more focused on the appointment itself. (2) Formality. State law requirements vary, but many states permit healthcare surrogate designations with simpler execution requirements (two witnesses, no notary; or one witness with notarization) than for durable powers. (3) Effective trigger. Most healthcare surrogate designations are "springing" — they take effect only on a determination by the attending physician that the principal lacks capacity. Some states permit immediate effectiveness with the surrogate sharing concurrent authority during periods of capacity. (4) Default surrogate. Every state has a default surrogate hierarchy that applies when no surrogate has been designated — typically: court-appointed guardian, spouse, adult children (sometimes unanimously), parents, siblings, other relatives, close friends. The hierarchy may not match your preferences (estranged adult children get priority over a long-term partner; a sibling who has been distant may outrank a close friend). Designating a surrogate by-passes the default and ensures the person you trust most is the decision-maker. (5) Out-of-state recognition. The Uniform Health-Care Decisions Act (UHCDA, 1993) is adopted in some form by 18 states; most other states have similar provisions; reciprocity is generally good but verify when moving across state lines. The form should include: (a) clear principal identification; (b) primary surrogate with full contact information; (c) alternate surrogate (highly recommended — surrogates have died, become disabled, or moved without the principal updating); (d) when authority becomes effective; (e) scope of authority including any specific limitations or instructions; (f) HIPAA authorization (without this, providers may not communicate freely with the surrogate); (g) relationship to other documents (advance directive, HPOA, POLST); (h) right to revoke; (i) principal signature; (j) witnesses or notary per state law. Witnesses must NOT be: the designated surrogate or alternate, a healthcare provider treating the principal, an employee of such provider, or (in some states) an heir or beneficiary of the principal's estate. Two unrelated, neutral adults are typical. Some states (Florida, others) permit some witnesses to be related to the principal but not both. Mental health treatment authority deserves special attention. State law often imposes additional requirements before a surrogate may consent to: (a) inpatient psychiatric admission, (b) electroconvulsive therapy, (c) experimental psychiatric treatment. Some states require a separate Psychiatric Advance Directive (PAD) for these decisions. The UHCDA approach generally permits surrogate authority over mental health treatment with the same restrictions as the principal would face. End-of-life decisions are central to surrogate authority. The form should clarify whether the surrogate may consent to withdrawal of life-sustaining treatment in line with the principal's known wishes; without explicit authorization, courts have sometimes required clear and convincing evidence of the principal's prior expressed preferences (the standard articulated in Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990)). The HIPAA authorization in the form is critical: 45 CFR § 164.502(g)(2) recognizes a "personal representative" with rights equivalent to the patient's, but only when the representative has authority under applicable law to make decisions related to the healthcare in question. Spelling out HIPAA authorization explicitly avoids friction with privacy officers who may not immediately recognize the surrogate's status. Storage and accessibility: the original should be filed with the principal's primary care provider, with copies to the surrogate, alternate, primary care, and any institution providing care. Some states (Oregon, California, others) have advance directive registries; check state options. The form should be brought to every major healthcare encounter and reviewed periodically (every 5-10 years or after major life events: marriage, divorce, death of a previously named surrogate, move to a new state, serious diagnosis).
When to use it
- Adult who wants to designate a specific person to make medical decisions if incapacitated.
- Patient who is satisfied with the default surrogate hierarchy in their state but wants to confirm preferred surrogate.
- Patient who wants to bypass the default hierarchy (e.g., long-term partner not yet married; preferred over adult children).
- Supplement to advance directive — separates "what I want" (advance directive) from "who decides" (this form).
- Routine adult preventive care; commonly completed at annual physicals.
What to include
- Principal's legal name, DOB, and address.
- Primary surrogate with full contact information including 24/7 phone.
- Alternate surrogate with full contact information.
- When authority becomes effective (typically: physician determines incapacity).
- Scope of authority including end-of-life decisions.
- Specific limitations or treatment preferences.
- HIPAA authorization for surrogate to access PHI.
- Relationship to other documents (advance directive, HPOA, POLST).
- Right to revoke and revocation methods.
- Principal signature with date.
- Witnesses (two, qualified per state law) or notary per state law.
- Copies provided to surrogate, alternate, primary care, and registry if available.