Sample Healthcare Proxy Form - Massachusetts
Below is an example of language used for a Massachusetts healthcare proxy
form. It is strongly recommended that individuals adapt the language to
meet their own needs and check the specific laws of their state of residence
(a helpful Web site is http://www.finance.cch.com/tools/poaforms_m.asp).
MASSACHUSETTS HEALTHCARE PROXY
OF
(CLIENT NAME)
TO ALL PEOPLE CONCERNED WITH MY MEDICAL CARE:
A. APPOINTMENT
I, (client name), residing at (address), ________County, Massachusetts,
being a competent adult of at least 18 years of age, of sound mind, and
under no constraint or undue influence, hereby appoint the following
person to be my HEALTHCARE AGENT under the terms of this document:
NAME:
Address:
Telephone:
In so doing, I create a Healthcare Proxy according to Chapter 201D of
the General Laws of Massachusetts. I hereby give my Healthcare Agent the
authority to make any and all healthcare decisions on my behalf, subject to
any limitations that I state in this document, in the event that, in the future,
I should become incapable of making healthcare decisions for myself.
If my original Healthcare Agent is unable or unwilling to serve, I hereby
appoint the following person as my Healthcare Agent:
NAME:
Address:
Telephone:
1
511
Sample Healthcare Proxy Form
Appendix G
Page 1/5
Free Download
Sample Healthcare Proxy Form - Massachusetts PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
