AB655,5,1110 (a) County adult protective services substantiated an allegation of neglect or
11abuse by the supporter.
AB655,5,1212 (b) The supporter is found criminally liable for conduct described under par. (a).
AB655,5,1413 (c) There is a restraining order against the supporter as described under s.
14813.123.
AB655,5,17 15(3) An adult with a functional impairment may revoke his or her supported
16decision-making agreement and invalidate the supported decision-making
17agreement at any time by doing any of the following:
AB655,5,2118 (a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
19the supported decision-making agreement or directing another in the presence of
20the adult with a functional impairment to so destroy the supported decision-making
21agreement.
AB655,5,2422 (b) Executing a statement, in writing, that is signed and dated by the adult with
23a functional impairment, expressing his or her intent to revoke the supported
24decision-making agreement.
AB655,6,2
1(c) Verbally expressing the intent of the adult with a functional impairment to
2revoke the supported decision-making agreement, in the presence of 2 witnesses.
AB655,6,5 3(4) Unless the supported decision-making agreement provides a different
4method for the supporter's resignation, a supporter may resign by giving notice to
5the adult with a functional impairment.
AB655,6,9 653.16 Access to personal information. (1) A supporter is only authorized
7to assist the adult with a functional impairment in accessing, collecting, or obtaining
8information that is relevant to a decision authorized under the supported
9decision-making agreement.
AB655,6,17 10(2) A supporter may assist with accessing or obtaining any information that
11will help the adult with a functional impairment make health care decisions,
12including medical, psychological, financial, education, or treatment records or
13research under ss. 51.30 and 146.83 and the federal Health Insurance Portability
14and Accountability Act of 1996, 45 CFR 164.502. A supporter may only access or
15obtain patient health care records, as defined under s. 146.81 (4), if the adult with
16a functional impairment has signed a release allowing the supporter to see protected
17health information, as defined under s. 146.816 (1) (f).
AB655,6,21 18(3) A supporter may assist with accessing or obtaining any information on
19education records under the federal Family Educational Rights and Privacy Act of
201974, 20 USC 1232g, if the adult with a functional impairment has signed a release
21allowing the supporter to access information under this subsection.
AB655,6,24 22(4) The supporter shall ensure the information under this section is kept
23privileged and confidential, as applicable, and is not subject to unauthorized access,
24use, or disclosure.
AB655,7,3
1(5) Notwithstanding the existence of a supported decision-making agreement,
2an adult with a functional impairment continues to have unrestricted access to
3personal information without the assistance of a supporter.
AB655,7,7 4(6) Notwithstanding the existence of a supported decision-making agreement,
5an adult with a functional impairment is able to request and receive assistance on
6any decision that is not covered under the supported decision-making agreement at
7any time.
AB655,7,11 853.18 Authorization and witnesses. (1) An adult with a functional
9impairment and his or her supporter entering into a supported decision-making
10agreement must sign and date the agreement in the presence of 2 or more subscribing
11witnesses or a notary public.
AB655,7,14 12(2) If the adult with a functional impairment and his or her supporter choose
13to sign and date the supported decision-making agreement before witnesses, the
14attesting witnesses must be at least 18 years of age.
AB655,7,18 1553.20 Supported decision-making agreement instrument; form. (1) A
16supported decision-making agreement is valid if it is in writing, entered into
17voluntarily as described under s. 53.10, signed and dated as described under s. 53.18,
18and in substantially the following form:
AB655,7,2119 SUPPORTED
20 DECISION-MAKING AGREEMENT
21 APPOINTMENT OF SUPPORTER
AB655,7,2222 I, .... (insert name), make this agreement voluntarily and of my own free will.
AB655,7,2323 I agree and designate that
AB655,7,2424 Name of supporter ....
AB655,7,2525 Address of supporter ....
AB655,8,1
1E-mail address of supporter ....
AB655,8,22 Phone number(s) of supporter ....
AB655,8,53 is my supporter. For the following everyday life decisions, if I have checked
4“Yes,” my supporter may help me with that type of decision, but if I have checked
5“No,” my supporter may not help me with that type of decision:
AB655,8,66 Obtaining food, clothing, and shelter — Yes.... No....
AB655,8,77 Taking care of my physical health — Yes.... No....
AB655,8,88 Managing my financial affairs — Yes.... No....
AB655,8,99 Taking care of my mental health — Yes.... No....
AB655,8,1010 Applying for public benefits — Yes.... No....
AB655,8,1211 Assistance with seeking vocational rehabilitation services and other vocational
12supports — Yes.... No....
AB655,8,1413 The following are other decisions I have specifically identified that I would like
14assistance with ....
AB655,8,1715 If I have not checked either “Yes" or “No" or specifically identified and listed a
16decision immediately above, my supporter may not help me with that type of
17decision.
AB655,8,1918 My supporter is not allowed to make decisions for me. To help me with my
19decisions, my supporter may do any of the following, if I have checked “Yes”:
AB655,8,2420 1. Help me access, collect, or obtain information, including records, relevant to
21a decision. If I have checked “Yes,” my supporter may help me access, collect, or
22obtain the type of information specified, including relevant records, but if I have
23checked “No,” or I have not checked either “Yes” or “No,” my supporter may not help
24me access, collect, or obtain that type of information:
AB655,8,2525 Medical — Yes.... No....
AB655,9,1
1Psychological — Yes.... No....
AB655,9,22 Financial — Yes.... No....
AB655,9,33 Education — Yes.... No....
AB655,9,44 Treatment — Yes.... No....
AB655,9,65 Other — Yes.... No.... (If “Yes,” specify the other type(s) of information with
6which the supporter may assist ....)
AB655,9,87 2. Help me understand my options so I can make an informed decision.
8 Yes.... No....
AB655,9,109 3. Help me communicate my decision to appropriate persons.
10 Yes.... No....
AB655,9,1511 4. Help me access appropriate personal records, including protected health
12information under the Health Insurance Portability and Accountability Act, the
13Family Educational Rights and Privacy Act, and other records that may or may not
14require a release for specific decisions I want to make.
15 Yes.... No....
AB655,9,17 16Effective Date of Supported
17 Decision-Making Agreement
AB655,9,2018 This supported decision-making agreement is effective immediately and will
19continue until .... (insert date), or until the agreement is terminated by my supporter
20or me or by operation of law.
AB655,9,2121 (print) Name of person designating a supporter ....
AB655,9,2222 Signature ....
AB655,9,2323 Date ....
AB655,9,24 24consent of supporter
AB655,10,3
1I know .... (name of person) personally or I have received proof of his or her
2identity and I believe him or her to be at least 18 years of age and entering this
3agreement knowingly and voluntarily. I am at least 18 years of age.
AB655,10,44 I, .... (name of supporter), consent to act as a supporter under this agreement.
AB655,10,55 Supporter:
AB655,10,66 (print) Name ....
AB655,10,77 Address ....
AB655,10,88 E-mail address ....
AB655,10,99 Phone number(s) ....
AB655,10,1010 Signature ....
AB655,10,1111 Date ....
AB655,10,14 12Statement AND SIGNATURE
13 OF WITNESSES OR
14 SIGNATURE OF NOTARY
AB655,10,1615 (This agreement must be signed either by 2 witnesses who are at least 18 years
16of age or by a notary public.)
AB655,10,1717 OPTION I: WITNESSES
AB655,10,2018 I know .... (name of person) personally or I have received proof of his or her
19identity and I believe him or her to be at least 18 years of age and entering this
20agreement knowingly and voluntarily. I am at least 18 years of age.
AB655,10,2121 Witness No. 1:
AB655,10,2222 (print) Name ....
AB655,10,2323 Address ....
AB655,10,2424 Phone number(s) ....
AB655,10,2525 Signature ....
AB655,11,1
1Date ....
AB655,11,22 Witness No. 2:
AB655,11,33 (print) Name ....
AB655,11,44 Address ....
AB655,11,55 Phone number(s) ....
AB655,11,66 Signature ....
AB655,11,77 Date ....
AB655,11,88 OPTION II: NOTARY PUBLIC
AB655,11,99 State of ....
AB655,11,1010 County of ....
AB655,11,1211 This document was acknowledged before me on .... (date), by .... (name of adult
12with a functional impairment) and ..... (name of supporter).
AB655,11,1313 Signature of notary ....
AB655,11,1414 (Seal, if any, of notary)
AB655,11,1515 Printed name ....
AB655,11,1616 My commission expires: ....
AB655,11,22 17(2) The department of health services shall prepare and provide access to a
18supported decision-making agreement instrument and accompanying information
19for adults with functional impairments, family members of adults with functional
20impairments, education professionals and school districts, health care and social
21service professionals, county clerks, and local bar associations. The department may
22charge a reasonable fee for the cost of preparation and distribution.
AB655,11,2523 Subchapter III
24 duty of certain persons
25 with respect to agreement
AB655,12,5
153.30 Reliance on agreement; limitation of liability. (1) A person who
2receives the original or a copy of a supported decision-making agreement shall rely
3on the agreement, except if the person has cause to believe that the adult with a
4functional impairment is being abused, neglected, unduly influenced, or financially
5exploited by the supporter as described under s. 53.32.
AB655,12,8 6(2) A person is not subject to criminal or civil liability and has not engaged in
7professional misconduct for an act or omission if the act or omission is done in good
8faith and in reliance on a supported decision-making agreement.
AB655,12,15 9(3) Any health care provider that respects and acts consistently with the
10authority given to a supporter by a duly executed supported decision-making
11agreement shall be immune from any action alleging that the agreement was invalid
12unless the entity, custodian, or organization had actual knowledge or notice that the
13adult with a functional impairment had revoked such authorization, that the
14agreement was invalid, or that the supporter had committed abuse, neglect, or
15financial exploitation as described in s. 53.14 (2) (a).
AB655,12,23 16(4) Any health care provider that provides health care based on the consent of
17an adult with a functional impairment, made with supports and services provided
18through a duly executed supported decision-making agreement, shall be immune
19from any action alleging that the adult with a functional impairment lacked capacity
20to provide informed consent unless the entity, custodian, or organization had actual
21knowledge or notice that the adult with a functional impairment had revoked such
22authorization, that the agreement was invalid, or that the supporter had committed
23abuse, neglect, or financial exploitation as described in s. 53.14 (2) (a).
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