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I further affirm that this designation is not being made as a condition of treatment or admission to a healthcare facility. I fully understand that this designation will permit my surrogate to make healthcare decisions and to provide withhold or withdraw consent on my behalf to apply for public benefits to defray the cost of healthcare and to authorize my admission to or transfer from a healthcare facility. Submitted to Ocala Family Care P. A. Page 1 of 2 Healthcare Surrogate Designation Name...
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