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Massachusetts Health Care Proxy - Massachusetts

Massachusetts Health Care Proxy Form. This is a Massachusetts form and can be used in General Statewide .
 Fillable pdf Last Modified 9/19/2008
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NOTICE: The following form is protected by federal copyright law. An individual may download and print a single copy for his or her personal use. Health care organizations, clinicians, professionals, and others can purchase the form in quantity, or secure a license from Massachusetts Health Decisions, the nonprofit publisher of the form and educational materials related to the Massachusetts Health Care Proxy. The form is available in English, Braille, and many non-English languages. Contact MHD at: For $6 postpaid, individuals may order a complete information packet including two copies of the form, a basic brochure called "Making Choices...", and a 16-page "User's Guide" in question-and-answer format. Massachusetts Health Decisions, Publications, PO Box 1407, Apex, NC 27502. MASSACHUSETTS HEALTH CARE PROXY Information, Instructions, and Form What does the Health Care Proxy Law allow? The Health Care Proxy is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions. It is an important document, however, because it concerns not only the choices you make about your health care, but also the relationships you have with your physician, family, and others who may be involved with your care. Read this and follow the instructions to ensure that your wishes are honored. Under the Health Care Proxy Law (Massachusetts General Laws, Chapter 201D), any competent adult 18 years of age or over may use this form to appoint a Health Care Agent. You (known as the "Principal") can appoint any adult EXCEPT the administrator, operator, or employee of a health care facility such as a hospital or nursing home where you are a patient or resident UNLESS that person is also related to you by blood, marriage, or adoption. Whether or not you live in Massachusetts, you can use this form if you receive your health care in Massachusetts. What can my Agent do? Your Agent will make decisions about your health care only when you are, for some reason, unable to do that yourself. This means that your Agent can act for you if you are temporarily unconscious, in a coma, or have some other condition in which you cannot make or communicate health care decisions. Your Agent cannot act for you until your doctor determines, in writing, that you lack the ability to make health care decisions. Your doctor will tell you of this if there is any sign that you would understand it. Acting with your authority, your Agent can make any health care decision that you could, if you were able. If you give your Agent full authority to act for you, he or she can consent to or refuse any medical treatment, including treatment that could keep you alive. Your Agent will make decisions for you only after talking with your doctor or health care provider, and after fully considering all the options regarding diagnosis, prognosis, and treatment of your illness or condition. Your Agent has the legal right to get any information, including confidential medical information, necessary to make informed decisions for you. Your Agent will make health care decisions for you according to your wishes or according to his/her assessment of your wishes, including your religious or moral beliefs. You may wish to talk first with your doctor, religious advisor, or other people before giving instructions to your Agent. It is very important that you talk with your Agent so that he or she knows what is important to you. If your Agent does not know what your wishes would be in a particular situation, your Agent will decide based on what he or she thinks would be in your best interests. After your doctor has determined that you lack the ability to make health care decisions, if you still object to any decision made by your Agent, your own decisions will be honored unless a Court determines that you lack capacity to make health care decisions. © Massachusetts Health Decisions 1991-2015 Licensed for use by the Massachusetts Medical Society American LegalNet, Inc. How do I fill out the form? 1 At the top of the form, print your full name and address. Print the name, address, and phone number of the person you choose as your Health Care Agent. (Optional: If you think your Agent might not be available at any future time, you may name a second person as an Alternate Agent. Your Alternate Agent will be called if your Agent is unwilling or unable to serve.) 2 Setting limits on your Agent's authority might make it difficult for your Agent to act for you in an unexpected situation. If you want your Agent to have full authority to act for you, leave the limitations space blank. However, if you want to limit the kinds of decisions you would want your Agent or Alternate Agent to make for you, include them in the blank. 3 BEFORE you sign, be sure you have two adults present who will be witnesses and watch you sign the document. The only people who cannot serve as witnesses are your Agent and Alternate Agent. Then sign and date the document yourself. (Or, if you are physically unable, have someone other than either witness sign your name at your direction. The person who signs your name for you should put his/her own name and address in the spaces provided.) 4 Have your witnesses fill in the date, sign their names and print their names and addresses. 5 OPTIONAL: On the back of the form are statements to be signed by your Agent and any Alternate Agent. This is not required by law, but is recommended to ensure that you have talked with the person or persons who may have to make important decisions about your care and that each of them realizes the importance of the task they may have to do. Who should have the original and copies? After you have filled in the form, remove this information page and make at least four photocopies of the form. Keep the original yourself where it can be found easily (not in your safe deposit box). Give copies to your doctor and/or health plan to put into your medical record. Give copies to your Agent and any Alternate Agent. You can give additional copies to family members, your clergy and/or lawyer, and other people who may be involved in your health care decisionmaking. How can I revoke or cancel the document? Your Health Care Proxy is revoked when any of the following four things happens: 1. You sign another Health Care Proxy later on. 2. You leg
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