52.20(1)(1) A supported decision-making agreement is valid if it is in writing, entered into voluntarily as described under s. 52.10, signed and dated as described under s. 52.18, and in substantially the following form: SUPPORTED DECISION-MAKING AGREEMENT
APPOINTMENT OF SUPPORTER
I, .... (insert name), make this agreement voluntarily and of my own free will.
I agree and designate that
Name of supporter ....
Address of supporter ....
E-mail address of supporter ....
Phone number(s) of supporter ....
is my supporter. For the following everyday life decisions, if I have checked “Yes,” my supporter may help me with that type of decision, but if I have checked “No,” my supporter may not help me with that type of decision:
Obtaining food, clothing, and shelter — Yes.... No....
Taking care of my physical health — Yes.... No....
Managing my financial affairs — Yes.... No....
Taking care of my mental health — Yes.... No....
Applying for public benefits — Yes.... No....
Assistance with seeking vocational rehabilitation services and other vocational supports — Yes.... No....
The following are other decisions I have specifically identified that I would like assistance with ....
If I have not checked either “Yes” or “No” or specifically identified and listed a decision immediately above, my supporter may not help me with that type of decision.
My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may do any of the following, if I have checked “Yes”:
1. Help me access, collect, or obtain information, including records, relevant to a decision. If I have checked “Yes,” my supporter may help me access, collect, or obtain the type of information specified, including relevant records, but if I have checked “No,” or I have not checked either “Yes” or “No,” my supporter may not help me access, collect, or obtain that type of information:
Medical — Yes.... No....
Psychological — Yes.... No....
Financial — Yes.... No....
Education — Yes.... No....
Treatment — Yes.... No....
Other — Yes.... No.... (If “Yes,” specify the other type(s) of information with which the supporter may assist ....)
2. Help me understand my options so I can make an informed decision.
Yes.... No....
3. Help me communicate my decision to appropriate persons.
Yes.... No....
4. Help me access appropriate personal records, including protected health information under the Health Insurance Portability and Accountability Act, the Family Educational Rights and Privacy Act, and other records that may or may not require a release for specific decisions I want to make.
Yes.... No....
EFFECTIVE DATE OF SUPPORTED
DECISION-MAKING AGREEMENT
This supported decision-making agreement is effective immediately and will continue until .... (insert date), or until the agreement is terminated by my supporter or me or by operation of law.
(print) Name of person designating a supporter ....
Signature ....
Date ....
CONSENT OF SUPPORTER
I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.
I, .... (name of supporter), consent to act as a supporter under this agreement.
Supporter:
(print) Name ....
Address ....
E-mail address ....
Phone number(s) ....
Signature ....
Date ....
STATEMENT AND SIGNATURE OF WITNESSES
OR SIGNATURE OF NOTARY
(This agreement must be signed either by 2 witnesses who are at least 18 years of age or by a notary public.)
OPTION I: WITNESSES
I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.
Witness No. 1:
(print) Name ....
Address ....
Phone number(s) ....
Signature ....
Date ....
Witness No. 2:
(print) Name ....
Address ....
Phone number(s) ....
Signature ....
Date ....
OPTION II: NOTARY PUBLIC
State of ....
County of ....
This document was acknowledged before me on .... (date), by (name of adult with a functional impairment) and ..... (name of supporter).
Signature of notary ....
(Seal, if any, of notary)
Printed name ....
My commission expires: ....
52.20(2)(2) The department of health services shall prepare and provide access to a supported decision-making agreement instrument and accompanying information for adults with functional impairments, family members of adults with functional impairments, education professionals and school districts, health care and social service professionals, county clerks, and local bar associations. The department may charge a reasonable fee for the cost of preparation and distribution. 52.20 HistoryHistory: 2017 a. 345; 2021 a. 238 s. 44. DUTY OF CERTAIN PERSONS WITH
RESPECT TO AGREEMENT
52.3052.30 Reliance on agreement; limitation of liability. 52.30(1)(1) A person who receives the original or a copy of a supported decision-making agreement shall rely on the agreement, except if the person has cause to believe that the adult with a functional impairment is being abused, neglected, unduly influenced, or financially exploited by the supporter as described under s. 52.32. 52.30(2)(2) A person is not subject to criminal or civil liability and has not engaged in professional misconduct for an act or omission if the act or omission is done in good faith and in reliance on a supported decision-making agreement. 52.30(3)(3) Any health care provider that respects and acts consistently with the authority given to a supporter by a duly executed supported decision-making agreement shall be immune from any action alleging that the agreement was invalid unless the entity, custodian, or organization had actual knowledge or notice that the adult with a functional impairment had revoked such authorization, that the agreement was invalid, or that the supporter had committed abuse, neglect, or financial exploitation as described in s. 52.14 (2) (a). 52.30(4)(4) Any health care provider that provides health care based on the consent of an adult with a functional impairment, made with supports and services provided through a duly executed supported decision-making agreement, shall be immune from any action alleging that the adult with a functional impairment lacked capacity to provide informed consent unless the entity, custodian, or organization had actual knowledge or notice that the adult with a functional impairment had revoked such authorization, that the agreement was invalid, or that the supporter had committed abuse, neglect, or financial exploitation as described in s. 52.14 (2) (a). 52.30(5)(5) Any public or private entity, custodian, or organization that discloses personal information about an adult with a functional impairment to a supporter who is authorized to access, collect, or obtain or assist the adult with a functional impairment in accessing, collecting, or obtaining that information shall be immune from any action alleging that it improperly or unlawfully disclosed such information to the supporter unless the entity, custodian, or organization had actual knowledge that the adult with a functional impairment had revoked such authorization. 52.30(6)(6) This section may not be construed to provide immunity from actions alleging that a health care provider has done any of the following: 52.30(6)(a)(a) Caused personal injury as a result of a negligent, reckless, or intentional act. 52.30(6)(b)(b) Acted inconsistently with the expressed wishes of an adult with a functional impairment. 52.30(6)(c)(c) Failed to provide information to either an adult with a functional impairment or his or her supporter that would be necessary for informed consent. 52.30(6)(d)(d) Otherwise acted inconsistently with applicable law. 52.30(7)(7) The existence or availability of a supported decision-making agreement does not relieve a health care provider of any legal obligation to provide services to individuals with disabilities, including the obligation to provide reasonable accommodations or auxiliary aids and services, including interpretation services and communication supports to individuals with disabilities under the federal Americans with Disabilities Act. 52.30(8)(8) A supporter acting in the context of a valid supported decision-making agreement is immune from civil liability for his or her acts or omissions in performing duties as the supporter if he or she performs the duties in good faith, in conformance with the supported decision-making agreement or document of the adult with a functional impairment, and with the degree and prudence that an ordinarily prudent person exercises in his or her own affairs. 52.30 HistoryHistory: 2017 a. 345; 2021 a. 238 s. 44. 52.3252.32 Reporting of suspected abuse, neglect, or financial exploitation. 52.32(1)(1) If a person who receives a copy of a supported decision-making agreement or is aware of the existence of a supported decision-making agreement has cause to believe that the adult with a functional impairment is being abused, neglected, or financially exploited by the supporter, the person may report under s. 46.90 or 55.043 the alleged abuse, neglect, or financial exploitation. 52.32(2)(2) Nothing in this section may be construed as eliminating or limiting a person’s requirement to report under any other statute or regulation. 52.32 HistoryHistory: 2017 a. 345; 2021 a. 238 s. 44.
