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

Massachusetts Health Care Proy Assignment Page 4

I understand that my Health Care Proxy’s authority will become effective if my attending

physician determines that I lack the capacity to make or to communicate my health care

decisions. I also understand that if I should regain this capacity, my Health Care Proxy’s

authority terminates immediately and that all decision-making authority returns to me.

_______________________________

___________________________

(your signature)

(date)

WITNESSES

(two required)

I, _______________________________, affirm that the above person, ___________________,

appeared to be at least 18 years of age, of sound mind, under no constraint or undue influence,

and did sign this Health Care Proxy in my presence.

_______________________________

___________________________

(witness signature)

(date)

I, _______________________________, affirm that the above person, ___________________,

appeared to be at least 18 years of age, of sound mind, under no constraint or undue influence,

and did sign this Health Care Proxy in my presence.

_______________________________

___________________________

(witness signature)

(date)

Massachusetts Health Care Proy Assignment Page 4