Massachusetts Medical Power of Attorney (POA) Form

A Medical Power of Attorney form is a commonly used legal document in the U.S. The name of the paper may vary from state to state. In the state of Massachusetts, the form is referred to as Health Care Proxy. Although the structure and terms may be different in each state, the forms have the same function regardless of the state. In Massachusetts, the medical power of attorney form is an independent document that can be attached to other forms (for example, a Living Will form).

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Unfortunately, there are lots of situations in which the form may come in handy. The document is used when a person wants to appoint a representative who will act and communicate wishes on the individual’s behalf in case of the latter’s becoming incapacitated due to the following reasons:

  • lapsing into a coma after having a stroke or brain damage;
  • having poor mental health that prevents an individual from making conscious and sensible decisions;
  • sinking into a permanent unconscious or vegetative state;
  • losing the ability to speak for themselves due to some severe disease or chronic mental disorder.

When someone faces such situations, the document can ensure the fulfillment of the principal’s wishes. The appointed agent is to act in accordance with the principal’s interests and beliefs. Thus, it is crucial to choose a reliable person to whom you can entrust such vital decisions. One of the requirements for an agent is mental competence.

It is no less important to consider completing the form in advance as it is impossible to predict what will happen next in our lives, so the situations listed above may occur to you at any moment regardless of your age. Completing the form is especially recommended to those who have already become severely ill or reached an advanced age (65+).

Massachusetts Laws and Requirements

When you decide to complete the form, first and foremost, get acquainted with statutes with regard to the document. Read the requirements carefully to avoid confusion.

As the law states, Section 2, Chapter 201D of MA General Law, in particular, the principal, a person who executes the document, must be no younger than 18 years old and of sound mind. According to the above-mentioned section, apart from the principal’s signature, the signatures of two witnesses must be provided. They acknowledge that the document is legal, and the declarant is capable of understanding the essence of the document and his or her actions. In Massachusetts, you don’t have to notarize the form to make it completely valid.

Following MA Gen L ch 201d § 3 (2019), there are certain requirements regarding your choice of an agent. Make sure that a person you designate as an attorney-in-fact is not your doctor or any other healthcare provider from whom you receive medical treatment unless they are not your spouse, child, or any other close relative.

The form comes into effect when a person’s physician verifies that the principle is no longer competent to communicate decisions.

Massachusetts Medical Power of Attorney Form Details

Document Name Massachusetts Medical Power of Attorney Form
State Form Name Massachusetts Health Care Proxy
State Laws Massachusetts General Laws, Chapter 201D
Signing Requirements Two Witnesses
Who Can’t Be the Agent? Chapter 201D, Section 3
Who Can’t Be the Witness? Chapter 201D, Section 2
Avg. Time to Fill Out 8 minutes
# of Fillable Fields 21
Available Formats Adobe PDF

Filling Out the Form

Once you have read all the requirements and laws that are to be taken into consideration, you can obtain the document and start filling it out. As an independent document, the form is not too time-consuming. It is only two pages long. For a better understanding of the completing procedure, follow the step-by-step instruction below.

  • Obtain the MPOA Template

First and foremost, download the form via the Internet. You can use our form building software if you want to do it quickly. Start inserting the information directly on your computer or print it to fill it out in handwriting and sign.

  • Insert the Principal’s Personal Details

The document starts with the declarant’s providing their personal information. Insert your full name and address, including a ZIP code. Do not forget to indicate your date of birth at the very top of the page.
Principal's personal details indication part of Massachusetts medical power of attorney form

  • Appoint an Agent

The next blank lines are meant for inputting the personal details belonging to the chosen agent. You should insert the name, address, and contacts (such as telephone numbers and e-mail). Make sure that your agent meets all the state requirements.
Agent appointment section of Massachusetts mpoa template

  • Add an Alternate Agent

In the state of Massachusetts, you are allowed to choose a backup agent who will have the same responsibilities as the agent you designated in the first place. These are certain situations that can prevent your primary attorney-in-fact from acting and communicating on your behalf. Fill in the personal information about the new agent (name, address, phone number).
Alternate agent adding of mpoa document for Massachusetts

  • Add Specific Instructions for the Agent

Read the statement regarding your agent’s authority carefully and try to determine whether you agree with the statement or not. If you want to set certain limitations on the agent’s scope of authority, specify them in the blank space below.
Specific instructions adding section of medical power of attorney template for Massachusetts

  • Provide Your Signature

You, as a declarant, must check the information you have provided several times and then sign the document. If you are physically unable to do it, appoint a representative to sign the paper on your behalf. Ask the representative to insert details regarding their name, full address (information required in all sections in which the identity of a person must be specified).
Signature part of medical power of attorney document for Massachusetts

  • Ask Two Witnesses to Sign

As has been stated above, the law demands that you should have two witnesses to sign the document to make it valid. Ask them to insert the date, their names, and addresses. Remember that your health care agent cannot be your witness.
Witnesses signing section of Massachusetts mpoa form

  • Ask the Agent(s) to Provide Their Signatures

The second page of the document is dedicated to the agent(s) statements claiming that they have agreed to take the responsibilities and realize the importance of their task. This part is not required by the state law, so you can leave it blank. However, it is recommended to ensure that your agent has read the document and agreed to fulfill your wishes.
Agent signature part of medical power of attorney template for Massachusetts

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Published: Apr 9, 2022