Massachusetts Health Care Proxy Form - Lawrence General Hospital printable pdf download

Lawrence General Hospital

MASSACHUSETTS HEALTH CARE PROXY FORM

I, ________________________________________________________________________(the principal),

___________

born on

and residing at

Massachussetts,

pursuant to Massachusetts General Laws Chapter 201D, appoint the following person to be my Health Care

Agent:

Name: ___________________________________ Phone #: ___________________________________

Address:______________________________ City/State/Zip: ___________________________________

If my Health Care Agent named above is not available or declines to serve, I name as an alternate Health

Care Agent:

Name: ___________________________________ Phone #: ___________________________________

Address: ______________________________ City/State/Zip: ___________________________________

I give my Health Care Agent authority to make all health care decisions on my behalf if I become incapable

of making such decisions for myself, including but not limited to decisions concerning initiation, continuing,

withdrawing or refusing any life-prolonging care, treatment, service or procedure, EXCEPT (here list the

limitations, IF ANY, you wish to place on your Agent’s authority):

____________________________________________________________________________________

My Health Care Agent shall make health care decisions for me in accordance with my Health Care Agent’s

assessment of my wishes, including my religious and moral beliefs. If my wishes are unknown, my Health

Care Agent shall make such decisions for me only in accordance with my Health Care Agent’s assessment of

my best interests.

My Agent may obtain any and all medical information, including

medical information, as I

A photocopy of this Health Care Proxy should be treated as an original. Anyone

would be entitled to receive.

who is given such photocopy is authorized to consider it to be the same as the original, and to act accordingly.

My Health Care Agent’s authority to act on my behalf shall exist only for the period during which my attending

physician determines that I lack capacity to make or communicate health care decisions for myself.

I sign this Health Care Proxy on ________________, 20_____ in the presence of two witnesses.

Signed: ___________________________________________________________

(If the Principal cannot sign)

e principal is unable to sign and at the direction of the principal I have signed

his/her name in his/her presence and in the presence of two witnesses.

Name: ______________________________________________________________________

Street: _____________________________ City/Town: ______________________________

Complete both sides

Massachusetts Health Care Proxy Form - Lawrence General Hospital