Fillable Printable Sample Healthcare Proxy Form - Massachusetts

Sample Healthcare Proxy Form - Massachusetts

Below is an example of language used for a Massachusetts healthcare proxy

form. It is strongly recommended that individuals adapt the language to

meet their own needs and check the specific laws of their state of residence

(a helpful Web site is http://www.finance.cch.com/tools/poaforms_m.asp).

MASSACHUSETTS HEALTHCARE PROXY

(CLIENT NAME)

TO ALL PEOPLE CONCERNED WITH MY MEDICAL CARE:

A. APPOINTMENT

I, (client name), residing at (address), ________County, Massachusetts,

being a competent adult of at least 18 years of age, of sound mind, and

under no constraint or undue influence, hereby appoint the following

person to be my HEALTHCARE AGENT under the terms of this document:

NAME:

Address:

Telephone:

In so doing, I create a Healthcare Proxy according to Chapter 201D of

the General Laws of Massachusetts. I hereby give my Healthcare Agent the

authority to make any and all healthcare decisions on my behalf, subject to

any limitations that I state in this document, in the event that, in the future,

I should become incapable of making healthcare decisions for myself.

If my original Healthcare Agent is unable or unwilling to serve, I hereby

appoint the following person as my Healthcare Agent:

NAME:

Address:

Telephone:

511

Sample Healthcare Proxy Form

Appendix G

B. POWERS OF HEALTHCARE AGENT

1. I give my Healthcare Agent full authority to make any and all health-

care decisions for me, including decisions about life-sustaining treatment,

subject only to any limitations that I state below.

2. My Healthcare Agent shall have authority to act on my behalf only if,

when and for so long as a determination has been made that I lack the

capacity to make or to communicate healthcare decisions for myself. This

determination shall be made in writing by my attending physician accord-

ing to accepted standards of medical judgment and the requirements of

Chapter 201D of the General Laws of Massachusetts.

3. The authority of my Healthcare Agent shall cease if my attending

physician determines that I have regained capacity. The authority shall

recommence if I subsequently lose capacity and consent for treatment is

required.

4. I shall be notified of any determination that I lack capacity to make

or communicate healthcare decisions where there is any indication that I

am able to comprehend this notice.

5. My Healthcare Agent shall make healthcare decisions for me only

after consultation with my healthcare providers and after consideration of

acceptable medical alternatives regarding diagnosis, prognosis, treatments,

and their side effects.

6. My Healthcare Agent shall make healthcare decisions for me in accor-

dance with his/her assessment of my wishes, my moral or religious beliefs,

or, if such factors are unknown, then in accordance with my Healthcare

Agent’s assessment of my best interests.

7. My Healthcare Agent shall have the right to receive any and all med-

ical information necessary to make informed decisions regarding my

healthcare, including any and all confidential medical information that I

would be entitled to receive.

8. If I object to a healthcare decision made by my Healthcare Agent, my

decision shall prevail unless it is determined by court order that I lack

capacity to make healthcare decisions.

9. The decisions made by my Healthcare Agent on my behalf shall have

the same priority as my decisions would have if I were competent over

decisions by any other person, except for any limitation I state below or a

specific court order overriding this proxy.

10. Nothing in this proxy shall preclude any medical procedure deemed

necessary by my attending physician to provide comfort care or pain alle-

viation including but not limited to treatment with sedatives and pain-

killing drugs, non-artificial oral feeding, suction, and hygienic care.

C. COURT-APPOINTED GUARDIAN

If it is deemed necessary to seek the appointment by a probate court of a

guardian of my person, I hereby nominate the persons named herein as my

512 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health

appointed Healthcare Agent and alternate Healthcare Agent for appoint-

ment by such court to serve as such fiduciary.

D. HIPAA RELEASE AUTHORITY

I hereby grant my Healthcare Agent release authority that applies to any

information governed by the Health Insurance Portability and

Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d, as now in effect, and

as such law may from time to time hereafter be amended. I intend that my

Healthcare Agent be treated as I would be, with respect to my rights regard-

ing the use and disclosure of my individually identifiable health informa-

tion and/or other medical records.

I hereby authorize any physician, healthcare professional, dentist,

health plan, hospital, clinic, laboratory, pharmacy, or other covered health-

care provider, any insurance company or healthcare clearinghouse that has

provided treatment or services to me, that has paid for or that is seeking

payment from me for such services, to give, disclose and release to my

Healthcare Agent, without restriction, all of my individually identifiable

health information and medical records regarding any past, present or

future medical or mental health condition.

The authority given to my Healthcare Agent under this Section D

supercedes any prior agreement that I may have made with my healthcare

providers with respect to disclosure of my individually identifiable health

information.

As long as this Healthcare Proxy remains in full force and effect, the

HIPAA release authority given under this Section D has no expiration date

and shall expire only in the event that I revoke the authority in writing and

deliver it to my healthcare provider.

E. REVOCATION

This Healthcare Proxy shall be revoked upon any one of the following

events:

a. my execution of a subsequent Healthcare Proxy

b. my divorce or legal separation from my spouse where my spouse is

named as my Healthcare Agent

c. my notification to my Healthcare Agent or a healthcare provider orally

or in writing or by any other act evidencing a specific intent to revoke

the Healthcare Proxy

SIGNATURE OF PRINCIPAL

I hereby sign my name on this _______ day of _____________________,

_____, to this Healthcare Proxy in the presence of two witnesses.

______________________________ Client Name

Appendix G: Sample Healthcare Proxy Form 513

If the principal is physically incapable of signing:

I hereby sign the name of the principal at the principal’s

direction and in the presence of the principal and two witnesses.

Name of Principal: _______________________________________

Name of Signatory: _______________________________________

Date: _______________________________________

Address of Signatory: _______________________________________

_______________________________________

WITNESSES:

We, the undersigned, have witnessed the signing of this document by the

principal or at the direction of the principal and state that to the best of our

knowledge, the principal is at least 18 years of age, of sound mind, and

under no constraint or undue influence. We, the witnesses, have not been

named as Healthcare Agents.

1. ______________________________ ___________

Witness (Sign) Date

______________________________

Print Name

____________________________________________________________

Address

2. ______________________________ ___________

Witness (Sign) Date

______________________________

Print Name

____________________________________________________________

Address

Notarization

Commonwealth of Massachusetts

County of _________________

On this ___________ day of _____________, _____, before me, the under-

signed, a notary public of the Commonwealth of Massachusetts, personally

appeared (client name), proved to me through satisfactory evidence of

identification, which was __________________________, personally known

to me or proven on the basis of satisfactory evidence to be the person

whose name is subscribed to this instrument, a Healthcare Proxy, and

acknowledged that he executed it voluntarily and for its stated purpose.

514 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health

Appendix G: Sample Healthcare Proxy Form 515

I declare under the penalty of perjury that the persons whose names are

subscribed to this instrument appear to be of sound mind and under no

duress, fraud, or undue influence.

__________________________________

My Commission Expires: _____________