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Fillable Printable Health Care Proxy Form - Massachusetts

Fillable Printable Health Care Proxy Form - Massachusetts

Health Care Proxy Form - Massachusetts

Health Care Proxy Form - Massachusetts

1
I, ________________________________________________________________________(the principal),
residing at________________________________________, __________________ County, Massachusetts,
pursuant to Massachusetts General Laws Chapter 201D, appoint the following person to be my Health Care
Agent:
Name:
___________________________________
Phone #:
Address:
______________________________
City/State/Zip:
If my Health Care Agent named above is not available, I name as an alternate Health Care Agent:
Name:
___________________________________
Phone #:
Address:
______________________________
City/State/Zip:
I give my Health Care Agent authority to make all health care decisions on my behalf if I become incapable
of making such decisions for myself, including but not limited to decisions concerning initiation, continuing,
withdrawing or refusing any life-prolonging care, treatment, service or procedure, EXCEPT (here list the
limitations, IF ANY, you wish to place on your Agent’s authority):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
My Health Care Agent shall make health care decisions for me in accordance with my Health Care Agent’s
assessment of my wishes, including my religious and moral beliefs. If my wishes are unknown, my Health
Care Agent shall make such decisions for me only in accordance with my Health Care Agent’s assessment of
my best interests.
My Agent may obtain any and all medical information, including confidential medical information, as I
would be entitled to receive. Photocopies of this Health Care Proxy shall have the same force and effect as the
original and may be given to other health care providers.
My Health Care Agent’s authority to act on my behalf shall exist only for the period during which my attending
physician determines that I lack capacity to make or communicate health care decisions for myself.
I sign this Health Care Proxy on ________________, 20_____ in the presence of two witnesses.
Signed:
___________________________________________________________
(If the Principal cannot sign) The principal is unable to sign and at the direction of the principal I have signed
his/her name in his/her presence and in the presence of two witnesses.
Name:
______________________________________________________________________
Street:
_____________________________
City/Town:
______________________________
MASSACHUSETTS HEALTH CARE PROXY FORM
MASSACHUSETTS HEALTH CARE PROXY FORM
We, the undersigned witnesses, each declare in the presence of the principal that neither of us has been named
as Health Care Agent or alternate Health Care Agent in this Health Care Proxy, and we further declare that
the principal signed this instrument as his/her Health Care Proxy, or directed its execution, in the presence
of each of us, that each of us signs this Health Care Proxy as witness in the presence of the principal, and
that to the best of our knowledge he/she is eighteen (18) years of age or over, of sound mind, and under no
constraint or undue influence.
Witness:
________________________________
Printed Name:
_____________________________
Address:
___________________________________________________________________________
Witness:
________________________________
Printed Name:
_____________________________
Address:
___________________________________________________________________________
ST A T E M E N T O F HE A L T H CA R E AG E N T (O P T I O N A L )
Health Care Agent:
I have been named by ______________________________________ (the “principal”)
as the principal’s
Health Care Agent
by his or her Health Care Proxy and I hereby accept this appointment.
Health Care Agent by his or her Health Care Proxy and I hereby accept this appointment. Health Care Agent
The principal has communicated to me his/her health care wishes at a time of possible incapacity, and I will
try to give effect to the principals wishes. I am not an operator, administrator or employee of a hospital,
nursing home, rest home, Soldiers Home or other health facility where the principal is presently a patient or
resident or has applied for admission; or if I am such a person, I am also related to the principal by blood,
marriage or adoption.
Signature of
Health Care Agent:
______________________________________
Date:
_____________
ST A T E M E N T O F AL T E R N A T E HE A L T H CA R E AG E N T (O P T I O N A L )
Alternate:
I have been named by __________________________________________________________
(the “principal”) as the principal’s
Alternate Health Care Agent
by his or her Health Care Proxy and I hereby
Alternate Health Care Agent by his or her Health Care Proxy and I hereby Alternate Health Care Agent
accept this appointment. The principal has communicated to me his/her health care wishes at a time of
possible incapacity, and I will try to give effect to the principal’s wishes. I am not an operator, administrator or
employee of a hospital, nursing home, rest home, Soldiers Home or other health facility where the principal
is presently a patient or resident or has applied for admission; or if I am such a person, I am also related to
the principal by blood, marriage or adoption.
Signature of
Alternate Health Care Agent:
______________________________
Date:
____________
This Health Care Proxy Form was prepared by The Central Massachusetts Partnership to Improve Care at the End of Life. The Partnership grants permission to
reproduce this document in its entirety, so long as the source, including this statement, is shown. 12/03
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