Durable Power of Attorney Example - Massachusetts

-vi-
Massachusetts Health Care Proxy
WILL TO LIVE FORM
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________
as my health care agent to make any health care decisions for me as authorized in this document
consistent with the instructions below.
If the person I designate above is unavailable, unwilling, or incompetent to serve and is not
expected to become available, willing or competent to make a timely medical decision given my
medical circumstances, I designate the following persons (each to act alone and successively, in
the order named):
A. First Successor Agent
(successor agent’s name)_________________________________________________________
(successor agent’s address)________________________________________________________
_____________________________________________________________________________
(successor agent’s phone number)__________________________________________________
B. Second Successor Agent
(second successor agent’s name)___________________________________________________
(second successor agent’s address)__________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
as my health care agent(s) to make any health care decisions for me as authorized in this
document consistent with the instructions below. This designation shall become effective only
when I become incapable of making or communicating my own health care decisions, as
determined pursuant to Mass. Gen. L. ch. 201D, § 6.
Any earlier designation is revoked.
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