Massachusetts Health Care Proxy (Page 3 of 3) in pdf

MASSACHUSETTS HEALTH CARE PROXY

I, ________________________________, (“the Principal”), residing at _________________

________________________________, Massachusetts, in accordance with chapter 201D of the

Massachusetts General Laws, appoint as my Health Care Agent:

Name: ___________________________

Telephone Numbers: _____________________

Address: ________________________

City/State/Zip Code: _____________________

If my Agent is unwilling or unable to serve, then I appoint as my Alternate Health Care Agent:

(Optional)

Name: ___________________________

Telephone Numbers: _____________________

Address: ________________________

City/State/Zip Code: _____________________

I authorize my Health Care Agent to make health care decisions for me, including decisions about

life-sustaining treatment if my attending physician determines, in writing, that I lack capacity to make or

communicate health care decisions, EXCEPT:

Describe any limitations here: _____________________________________________________

______________________________________________________________________________

I authorize my Agent to receive any and all medical information about my health care, or me, and to

disclose the information to others.

My Agent shall make health care decisions for me after consulting with my health care providers, and

considering acceptable medical alternatives regarding my diagnosis, prognosis, treatments and their side

effects. My Agent shall make health care decisions for me according to my wishes, including my

religious and moral beliefs. If my wishes are not known, my Agent shall make decisions according to

what my Agent determines to be in my best interest.

Photocopies of this Health Care Proxy shall have the same force and effect as the original. My Agent

may place a photocopy of this instrument in my medical records.

__________________________

Signature of Principal

We, the undersigned, each witnessed the signing of this Health Care Proxy by the Principal. Neither of us

has been named as Agent or Alternate Agent in this Health Care Proxy. We declare that the Principal

signed this Health Care Proxy in our presence, that the Principal signed it willingly, and 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.

Signed and witnessed, on this _______________ day of _____________________, 20 ____.

_____________

___

Witness #1

Address

____________________________________________________________________________

Witness #2

Address

Prepared by Volunteer Lawyers Project

Massachusetts Health Care Proxy Page 3