When a physician finds that a Baker Act patient's mental illness leaves them unable to make a well-reasoned, willful and knowing treatment decision, this form certifies that finding and records whether a health care surrogate or proxy will decide until the court appoints a guardian advocate. Page 2 notifies the surrogate or proxy of their authority and its limits.
The examining physician completes page 1, including the date and time of the exam and license number. The facility administrator or designee signs the page 2 notification to the surrogate or proxy.
Download the current version from the source each time; forms change without notice.
Certification of Person's Incompetence to Consent to Treatment and Notification of Health Care Surrogate/Proxy
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If the person has no surrogate named in an advance directive, the proxy is chosen in this order: judicially appointed guardian, spouse, adult child, parent, adult relative, close friend with an affidavit, then a licensed clinical social worker selected by a bioethics committee.
Yes. The Florida Department of Children and Families lists a Spanish version of CF-MH 3122 alongside the English Word form on its Baker Act forms page, so the surrogate notice can be given in Spanish where needed.
Under the page 2 notice, the surrogate or proxy receives the same information a guardian advocate would and must meet and talk with the person and the person's physician, in person if at all possible or by telephone if not.