Ma Health Care Proxy Form PDF Details

Understanding and preparing for healthcare decisions can be an overwhelming process, yet it's an integral part of planning for the future. The Massachusetts Health Care Proxy form serves as a vital tool in this planning, allowing individuals to appoint a Health Care Agent who will have the authority to make healthcare decisions on their behalf in the event that they are no longer able to do so themselves. This appointment takes into consideration not only decisions around life-sustaining treatment but also respects any limitations the principal might place on the agent’s authority. The form becomes effective upon the attending physician's determination that the principal lacks the capacity to make or communicate health care decisions. It also includes provisions for an Alternate Agent, ensuring continuity in representation if the primary agent is unable or unwilling to serve. In addition to the necessary signatures, the process includes witness stat

QuestionAnswer
Form NameMa Health Care Proxy Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshealth care proxy form massachusetts, health care proxy massachusetts form, health care proxy form, health proxie form

Form Preview Example

YOUR BIRTH DATE (m/d/y)

_____/_____/_____

MASSACHUSETTS HEALTH CARE PROXY

1

I, ___________________________________________________________________, residing at

(Principal: PRINT your name)

___________________________________________________________________________________

(Street)(City/town)(State/ZIP)

appoint as my Health Care Agent: ____________________________________________________

(Name of person you choose as Agent)

of_________________________________________________________________________________

(Street)(City/town)(State/ZIP)

Agent’s tel (h) ____________________ (w) ____________________ E-mail __________________

OPTIONAL: If my agent is unwilling or unable to serve, then I appoint as my Alternate Agent:

______________________________________________________________________________________

(Name of person you choose as Alternate Agent)

of______________________________________________________________________________________

(Street)

(City/town)

(State/ZIP)

(Phone)

2My Agent shall have the authority to make all health care decisions for me, including decisions about life-sustaining treatment, subject to any limitations I state below, if I am unable to make health care decisions myself. MyAgent’s authority becomes effective if my attending physician determines in writing that I lack the capacity to make or to communicate health care decisions. My Agent is then to have the same authority to make health care decisions as I would if I had the capacity to make them EXCEPT (here list the limitations, if any, you wish to place on your Agent’s authority):

I direct myAgent to make health care decisions based on myAgent’s assessment of my personal wishes. If my personal wishes are unknown, my Agent is to make health care decisions based on my Agent’s assessment of my best interests. 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.

3

Signed:____________________________________ Date: ___/___/___ (mo/day/yr)

Complete only if Principal is physically unable to sign: I have signed the Principal’s name above at his/her direction in the presence of the Principal and two witnesses.

_______________________________________________________ _________________________________________________________

(Name)(Street)

_________________________________________________________

(City/town) (State/ZIP)

4WITNESS STATEMENT: We, the undersigned, each witnessed the signing of this Health Care Proxy by the Principal or at the direction of the Principal and state that the Principal appears to be at least 18 years of age, of sound mind and under no constraint or undue influence. Neither of us is named as the Health Care Agent or Alternate Agent in this document.

In our presence, on this day ____/____/____ ( mo / day / yr).

Witness #1 _____________________________

Witness #2 _____________________________

(Signature)

(Signature)

Name (print) ___________________________

Name (print) ___________________________

Address _______________________________

Address _______________________________

______________________________________

______________________________________

5

Statements of Health Care Agent and Alternate Agent (OPTIONAL)

Health Care Agent: I have been named by the Principal as the Principal’s Health Care Agent by this Health Care Proxy. I have read this document carefully, and have personally discussed with the Principal his/her health care wishes at a time of possible incapacity. I know the Principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health facility where the Principal is presently a patient or resident or has applied for admission. But if I am a person so described, I am also related to the Principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the Principal’s wishes.

(Signature of Health CareAgent)______________________________________________________

Alternate Agent: I have been named by the Principal as the Principal’s Alternate Agent by this Health Care Proxy. I have read this document carefully, and have personally discussed with the Principal his/her health care wishes at a time of possible incapacity. I know the Principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health facility where the Principal is presently a patient or resident or has applied for admission. But if I am a person so described, I am also related to the Principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the Principal’s wishes.

(Signature of AlternateAgent)________________________________________________________

* * * * *

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This PDF form requires particular information to be filled out, thus you should definitely take your time to enter exactly what is requested:

1. First, when filling out the massachusetts medical proxy form, start with the section that features the subsequent blank fields:

Filling out segment 1 in ma health proxy form

2. After completing this step, head on to the next part and enter the essential details in all these blank fields - I direct my Agent to make health, Signed Date modayyr, Complete only if Principal is, Name Street, Citytown StateZIP, WITNESS STATEMENT We the, Witness, Witness, Signature, Signature, Name print, Name print, Address, and Address.

Step no. 2 of filling out ma health proxy form

Lots of people generally get some points incorrect when filling out Address in this section. Be sure to read again what you type in right here.

3. Completing Health Care Agent I have been, Signature of Health Care Agent, Alternate Agent I have been named, and Signature of Alternate Agent is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Stage number 3 of completing ma health proxy form

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