Massachusetts Health Care Proy Assignment (Page 3 of 4) in pdf

Massachusetts Health Care Proy Assignment Page 3

Massachusetts Health Care Proxy Assignment

— Authorized by the Massachusetts General Laws, Title II, Chapter 201D, 2005 —

I, ___________________________________, being at least 18 years of age, in sound mind,

and under no duress or pressure, do hereby designate ________________________________,

to be my Health Care Proxy, should I become incapacitated and unable to communicate my

wishes about my medical care. I authorize my Health Care Proxy to make any and all medical

decisions on my behalf, with the exception of any limitations listed below. If my original Health

Care Proxy is unable or unwilling to make decisions on my behalf, I designate

_______________________________ to be my Alternate Health Care Proxy.

(Check one)

____ A. I give my Health Care Proxy full and complete authority to make any and all medical

decisions on my behalf

____ B. I place the following limitations on the decision-making powers of my Health Care

Proxy:

_____________________________________________________________________________

Massachusetts Health Care Proy Assignment Page 3