Free MA Health Care Proxy Form: Massachusetts Medical POA
A MA health care proxy form is a Massachusetts medical power of attorney. State law calls the form a health care proxy, and a competent adult uses it to appoint a health care agent.[1.1] This page explains the signing and witness rules in plain words, then walks through each part of the free FormsPal form with sample entries.
Last Updated: October 2026. This guide is reviewed and updated regularly to reflect current Massachusetts law. If you notice an error or outdated information, please contact us.
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A medical power of attorney, also called a healthcare power of attorney, is a form in which you name an agent to make healthcare decisions for you. In Massachusetts it is called a health care proxy and your agent is called a health care agent.[1.1] The agent speaks for you when you are unable to speak for yourself.
People often put a proxy in place before a situation like these arises:
A coma after a stroke or a brain injury
An illness that makes it hard to make clear decisions
A permanent unconscious state
A severe disease that takes away the ability to speak for yourself
Nobody can predict when one of these will happen. Family members often find it easier when your wishes, preferences and choices about treatment are written down in advance.
Health Care Proxy Requirements
State law sets out how a health care proxy is signed and witnessed in Chapter 201D, Section 2 of the Massachusetts General Laws.[1.2] The section below puts those rules in plain words so you can check them before you sign. Anything marked as common practice is advice, not law.
Signing Rules in Plain Words
Said health care proxy shall be in writing signed by such adult or at the direction of such adult in the presence of two other adults who shall subscribe their names as witnesses to such signature.
In plain words, the proxy is a written form. The principal signs it, or another person signs at the principal's direction. The signing happens in the presence of two other adults, who sign their names as witnesses to that signature.[1.2]
Before you sign, it helps to have these ready, as a matter of common practice:
The completed form, printed and read in full
Two other adults who can watch you sign and sign as witnesses themselves
The contact details of your agent
The details of an alternate agent, if you want one
The rule quoted above names a signature and two witnesses. It does not mention a notary. The FormsPal template also has a notary acknowledgment on page 7, and a lawyer can tell you whether to use it.
The FormsPal template is titled Medical Power of Attorney with Advance Directive and runs nine pages. What each part says comes from the printed text of the form, not from the state's law. Read all of it before you sign.
Part I, Power of Attorney for Health Care (pages 1 to 5). You name your agent and an alternate agent here. The powers cover medical care, access to medical records, hiring healthcare staff, pain relief and personal care. Paragraph 2 says the agent acts once the principal’s treating physician certifies in writing that the principal lacks capacity to make healthcare decisions.
Part II, Advance Health Care Directive (page 5). This part states your end-of-life wishes. The printed wording asks your healthcare providers to withhold or withdraw all treatment other than what keeps you comfortable in the situations it lists.
Part III, General Provisions (pages 5 and 6). These are standard terms for the whole form. The date and signature lines come right after them.
Notary acknowledgment (page 7). A notary public completes this page.
General Information (page 8). This page explains in plain words what the form gives your agent.
Signing and witnesses (page 9). This page has two blocks, one per witness, each with lines for a signature, a printed name, an address and a date.
Part II is a serious statement about end-of-life care, so check that it matches your wishes. If it does not, talk to a lawyer or your doctor before you sign.
Questions to Settle Before You Sign
A health care proxy works best when the people involved know what you want. These questions are common practice, not legal requirements. Talk them through with your agent and your doctor before you fill in the form.
Does the person you have in mind agree to serve as your agent?
Does your agent know your healthcare wishes, your preferences for treatment and your choices about life-sustaining care?
Who will hold the original, and who will get copies?
Are you planning for money or property too? Those are separate forms. See our durable page and our general power of attorney guide.
How to Fill Out the Health Care Proxy Form Step by Step
The form has 29 fillable fields across its nine pages, and the six steps below follow it from page 1 to page 9. Each step names the part of the form it covers. If you download the PDF, you can fill it in with our PDF editor or print it and write your answers by hand.
The screenshots under each step show the FormsPal Massachusetts medical power of attorney template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.
Name the principal and the agent. On page 1, write your full name and home address as the principal. Next, write the full name and address of the person you appoint as your agent. There is no effective date to choose here, because paragraph 2 of the form sets when the agent’s authority begins. Step 1: sample entries, not a real document.
Add contact details and the alternate agent. Still on page 1, enter the agent’s phone, email and alternative contact. In the ALTERNATE AGENT paragraph, repeat the agent’s name, then add the alternate’s name, address, phone, email and alternative contact. The form says the alternate steps in if the first agent resigns, dies, or is unable or unwilling to act. Step 2: sample entries, not a real document.
Date, sign and print your name. Read pages 2 to 5 first. Then go to page 6, enter the date on the line that begins “I have hereunto set my hand on”, sign on the signature line and print your name below it. Sign only when your two witnesses are present.[1.2]Step 3: sample entries, not a real document.
Notary acknowledgment details. Page 7 is the acknowledgment page for a notary public. If you use one, the lines hold the county, the date, the officer’s name and title, and the principal’s name. Step 4: sample entries, not a real document.
Notary signature and seal. At the bottom of page 7, the notary signs on the Signature (Seal) line and adds the official seal. Step 5: sample entries, not a real document.
Two witness blocks. On page 9, each of the two witnesses signs, prints a name, and writes an address and date in their own block. Page 9 also says the person named as health care agent may not act as a witness.[1.2]Step 6: sample entries, not a real document.
Signing and Using Your Health Care Proxy
Filling in the blanks is only part of the job. The steps below cover what happens around the form, from reading it to handing out copies. Follow the signing rules from the requirements section of this page.
Read the whole form. Go through Parts I to III and the pages that follow. Check that Part II matches your wishes.
Talk to your agent. It is common practice to confirm that the person agrees to serve and knows what you want.
Choose two witnesses. They must be two other adults, and the person named as health care agent cannot be one of them.[1.2]
Sign with the witnesses present. You sign, or another person signs at your direction, and the witnesses sign their names as witnesses to that signature.[1.2]
Decide about the notary page. Page 7 of the template is a notary acknowledgment, so ask a lawyer whether you need it.
Keep and share copies. It is common practice to keep the original somewhere safe and give copies to your agent and your doctor.
Common Mistakes to Avoid
Most problems with a health care proxy come from skipped steps, not from the blanks on the form. These mistakes are worth a quick check before you sign, based on the signing rules earlier on this page and on how the template is built.
Signing alone, when the proxy must be signed in the presence of two other adults who sign as witnesses.[1.2]
Asking the person named as health care agent to act as a witness, which the law does not allow.[1.2]
Skipping Part II, which states your end-of-life wishes and deserves a careful reading.
Leaving the alternate agent lines blank when you want a backup.
Keeping the only copy in a drawer, when it is common practice to give copies to your agent and your doctor.
Frequently Asked Questions
These answers come from Chapter 201D, Section 2 of the Massachusetts General Laws. Each one is short and marked with its source. For questions about your own situation, ask a lawyer.
Who can make a health care proxy in Massachusetts?
A competent person who is eighteen years of age or older may make one. State law gives every competent adult the right to appoint a health care agent by executing a health care proxy.[1.1]
Are witnesses required for a health care proxy?
Yes, at least two witnesses are required. The two other adults sign their names as witnesses to the principal’s signature.[1.2]
Can the health care agent also be a witness?
No. A person who has been named as health care agent in a health care proxy may not act as a witness to the signing of that proxy.[1.2]
What do the witnesses have to confirm?
The witnesses affirm in writing that the principal appeared to be at least eighteen years of age, of sound mind and under no constraint or undue influence.[1.2]
Other Massachusetts Forms
Interested in more Massachusetts documents? We provide free forms and simple customization experience to anyone who prefers having fewer to none challenges when handling paperwork.
Download a Free Massachusetts Medical Power of Attorney Form
You can download the form as a PDF with 29 fillable fields, or build it online and print it. Either way, you still need to sign it with two adult witnesses present, as the state’s signing rule requires.[1.2]
Create a free high-quality Massachusetts Medical Power of Attorney online now!
Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.
