Massachusetts Health Care Proxy (Page 2 of 4) in pdf

Massachusetts Doesn't have a Living Will statuate at this time so no advanced

directive is available in Massachusetts. A Healthcare Proxy is available.

MASSACHUSETTS HEALTH CARE PROXY – PAGE 1 OF 2

(1) I, __________________________________________, hereby appoint

(name)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(name, home address and telephone number of proxy)

as my health care proxy to make any and all health care decisions for me,

except to the extent that I state otherwise below.

This Health Care Proxy shall take effect in the event that a determination

is made by my attending physician that I lack the capacity to make or to

communicate my own health care decisions. My attending physician shall

make such determination in writing, and shall include his or her opinion

regarding the cause and nature of my incapacity, as well as its extent and

probable duration.

(2) Name of alternate proxy if the person I appoint above is unable,

unwilling or unavailable to act as my health care proxy (optional):

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(name, home address and telephone number of alternate proxy)

(3) I direct my proxy to make health care decisions in accord with my

wishes and limitations as may be stated below, or as he or she otherwise

knows. If my wishes are unknown, I direct my proxy to make health care

decisions in accord with what he or she determines to be my best

interests.

MASSACHUSETTS HEALTH CARE PROXY — PAGE 2 OF 2

(4) Other directions (optional):

(5) Signature: ______________________________ Date:______________

Address:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Statement by Witnesses

I declare that the person who signed this document appears to be at least

eighteen years of age, of sound mind, and under no constraint or undue

influence. He or she signed (or asked another to sign for him or her) this

document in my presence. I am not the person appointed as proxy or

alternate proxy by this document.

Witness 1: ____________________________________________________

Address: ______________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Massachusetts Health Care Proxy Page 2