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(c) Assist the adult with a functional impairment in understanding the
21information described in par. (b).
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(d) Assist the adult with a functional impairment in communicating the adult's
23decisions to appropriate persons.
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24(2) A supporter is not a surrogate decision maker for the adult with a functional
25impairment and does not have the authority to sign legal documents on behalf of the
1adult with a functional impairment or bind the adult with a functional impairment
2to a legal agreement.
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353.12 Authority of supporter. A supporter may exercise the authority
4granted to the supporter in the supported decision-making agreement.
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553.14 Term of agreement; revocation. (1) Except as otherwise provided
6in this section, a supported decision-making agreement extends until terminated by
7either party or by the terms of the agreement.
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8(2) A supported decision-making agreement is terminated if any of the
9following are true:
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(a) County adult protective services substantiated an allegation of neglect or
11abuse by the supporter.
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(b) The supporter is found criminally liable for conduct described under par. (a).
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(c) There is a restraining order against the supporter as described under s.
14813.123.
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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:
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(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.
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(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.
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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.
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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:
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SUPPORTED
20
DECISION-MAKING AGREEMENT
21
APPOINTMENT OF SUPPORTER
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I, .... (insert name), make this agreement voluntarily and of my own free will.
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I agree and designate that
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Name of supporter ....
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Address of supporter ....
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1E-mail address of supporter ....
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Phone number(s) of supporter ....
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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:
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Obtaining food, clothing, and shelter — Yes.... No....
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Taking care of my physical health — Yes.... No....
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Managing my financial affairs — Yes.... No....
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Taking care of my mental health — Yes.... No....
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Applying for public benefits — Yes.... No....
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Assistance with seeking vocational rehabilitation services and other vocational
12supports — Yes.... No....
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The following are other decisions I have specifically identified that I would like
14assistance with ....
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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.
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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”:
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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:
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Medical — Yes.... No....
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1Psychological — Yes.... No....
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Financial — Yes.... No....
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Education — Yes.... No....
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Treatment — Yes.... No....
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Other — Yes.... No.... (If “Yes,” specify the other type(s) of information with
6which the supporter may assist ....)
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2. Help me understand my options so I can make an informed decision.
8
Yes.... No....
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3. Help me communicate my decision to appropriate persons.
10
Yes.... No....
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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....
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16Effective Date of Supported
17
Decision-Making Agreement
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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.
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(print) Name of person designating a supporter ....
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Signature ....
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24consent of supporter
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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.
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I, .... (name of supporter), consent to act as a supporter under this agreement.
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(print) Name ....
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E-mail address ....
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Phone number(s) ....
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Signature ....
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12Statement AND SIGNATURE
13
OF WITNESSES OR
14
SIGNATURE OF NOTARY
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(This agreement must be signed either by 2 witnesses who are at least 18 years
16of age or by a notary public.)
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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.
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Witness No. 1:
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(print) Name ....
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Address ....
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Phone number(s) ....
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Signature ....
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Witness No. 2:
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(print) Name ....
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Phone number(s) ....
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Signature ....
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OPTION II: NOTARY PUBLIC
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State of ....
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County of ....
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This document was acknowledged before me on .... (date), by .... (name of adult
12with a functional impairment) and ..... (name of supporter).
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Signature of notary ....
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(Seal, if any, of notary)
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Printed name ....
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My commission expires: ....
