Health Care Proxy Form - Massachusetts
1
I, ________________________________________________________________________(the principal),
residing at________________________________________, __________________ County, Massachusetts,
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, 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 confidential medical information, as I
would be entitled to receive. Photocopies of this Health Care Proxy shall have the same force and effect as the
original and may be given to other health care providers.
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) The 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:
______________________________
MASSACHUSETTS HEALTH CARE PROXY FORM
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