Massachusetts Health Care Proxy printable pdf download

MASSACHUSETTS HEALTH CARE PROXY

What is a Health Care Proxy?

A Health Care Proxy allows you to appoint a Health Care Agent to make health care decisions

for you, if for any reason, you are unable to make or communicate decisions. Massachusetts

General Laws, chapter 201D, allows any adult of sound mind who is at least 18 years of age to

complete this form and to appoint a Health Care Agent.

Who can I appoint as my Health Care Agent?

You may appoint any adult EXCEPT anyone who is an operator, administrator or employee of a

health care facility, in which you are a patient or resident or to which you have applied for

admission, UNLESS that person is also related to you by blood, marriage or adoption.

What are the powers of a Health Care Agent?

Your Health Care Agent has the power to make any and all health care decisions on your behalf,

including decisions about life-sustaining treatment. Your Health Care Agent’s authority begins

only after your attending physician states, in writing, that you are unable to make or

communicate health care decisions. Your physician must notify you of his or her determination

that you lack the capacity to make health care decisions if there is any indication that you will

understand.

After consulting with your health care providers, and considering your diagnosis, prognosis,

treatment options and side effects, your agent has the power to make health care decisions in

accordance with his or her understanding of your wishes, religious or moral beliefs. If your

Agent does not know your wishes, your Agent will make decisions based upon your best

interests.

Your Health Care Agent can consent or refuse any medical treatment, for which you would be

able to grant your consent or refusal. Your agent will have the right to receive all of your

confidential medical information necessary to make informed decisions regarding your health

care.

You have the right to limit your Health Care Agent’s powers in any way you choose. To do so,

you should specifically describe any limitation you intend to impose upon your Health Care

Agent’s authority in your Health Care Proxy in the space provided. Because you cannot predict

your future medical needs, it is important that you give your Health Care Agent the broadest

possible powers.

The authority of your Health Care Agent will end when you recover sufficiently to be able to

make and communicate health care decisions.

How do I complete a Health Care Proxy?

You are the “Principal.” The person you appoint as your Health Care Agent is your “Agent.”

Your “Alternate Health Care Agent” is the person you may appoint in case your first choice for a

Health Care Agent is unavailable or unwilling. Be sure to complete the form fully and provide

all addresses and telephone numbers.

Prepared by Volunteer Lawyers Project

Massachusetts Health Care Proxy