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Massachusetts Health Care Proxy (Medical POA) Form

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The Massachusetts health care proxy, also referred to as a medical power of attorney,  allows an individual to appoint an individual to represent their medical interests if they, for some reason, are unable to speak for themselves. The document can be useful to have in place in the event you are incapacitated in an accident or otherwise and can’t communicate your wishes with your medical staff.

Definition –  (Health Care Proxy)


Living Will – Instruct health care providers if a patient would like to have feeding or breathing continue if they should be in a vegetative state with little to no chance to cure.

Durable (Financial) Power of Attorney – This POA continues after incapacitation and elects a trusted representative to make financial decisions on your behalf.

How to Write

1 – Obtain the Massachusetts Paperwork To Declare A Health Care Proxy

This page shall provide an image previewing the Health Care Proxy form required and three file type choices. If you have viewed the preview and this is the correct form, then open any of the labeled file type buttons below the image with the appropriate software program or use a current browser to open the PDF version and print it.

2 – Record The Identity Of The Principal And The Health Care Proxy

Section 1 of this paperwork will present a structured statement where the Principal may name the Health Care Agent or Proxy who he or she wishes to make Medical Decisions when the Principal needs them too. While the language presented is fairly standard it must be supplemented with some personal information to make the form applicable.

To begin, the Principal should print his or her name on the line labeled “Principal: Print Your Name.” The Principal is the individual granting the Health Care Proxy with decision making power in his or her Health Care.The next empty line will be subdivided with three labels “Street,” “City/Town,” and “State/Zip.” This will refer to the Principal’s Home Address. Enter the Principal’s Address precisely as it appears on his or her Identification.The next task that must be tended to will be to name the Health Care Agent being granted Power through this paperwork. Use the blank space immediately following the words “Health Care Agent,” to enter this person’s Full Name.The next immediate blank space will call for the Health Care Agent’s Full Residential Address. This must be the Physical Address that is presented on his or her I.D. (it is likely he or she will need to present I.D. at a Health Care Facility).There will be a third line calling for three pieces of information regarding the Health Care Agent. Use this line to report the Agent’s Home Telephone Number, Work Telephone Number, and E-Mail Address.In some cases, the Principal may want the assurance that his or her needs will be met regardless of the availability or ability of the Primary Health Care Agent just reported. If this is such a case, then under the word “Optional” the Principal may name an Alternate Health Care Agent. This is somewhat like the concept of having an Agent in reserve who may step in to make any necessary Health Care decisions if the Primary Health Care Agent cannot make such decisions for one reason or another (i.e. he or she may be out of the country, unwilling, etc.).

If an Alternate Health Care Agent has been determined by the Principal, then enter his or her Legal Name on the blank line labeled “Name Of Person You Choose As Alternate Agent.” Follow this declaration up by entering the Complete Residential Address and Phone Number on the next blank line. This line will be subdivided by labels to present such information clearly (Street, City/Town, State/Zip, Phone).3 – Name Any Limitations To The Health Care Proxy’s Principal Decision Making Powers

The decision-making Powers granted to the Health Care Agent(s) will be fairly all encompassing. The Principal should read section 2 to get an idea of the broad scope of decision making Powers being delivered to the Agent. If there are any limitations or restrictions that should apply to these Decision-Making Powers, they must be documented in the space below the words “Except (here list the limitations, if any, you wish to place on your Agent’s Authority.” You may continue this on a separate document if you are entering information by hand or, if entering information directly onscreen with an editing program, you may simply add more space. Make sure all limitations and restrictions the Principal wishes imposed on this paperwork’s Effect is clearly documented.

4 – The Intent Of the Principal May Only Be Substantiated With His Or Her Signature

Section 3 will, again, provide some standard language that is, nonetheless, required to properly issue this Power designation. The Principal should read this paragraph, then Sign his or her Name on the blank space labeled “Signed” next to the number 3. Adjacent to this, the Principal must enter the Date he or she signed this paperwork.Due to the nature of this designation of Authority, the Principal may elect to have an individual with the Power to sign on his or her behalf to issue this Power to the Health Care Proxy through Principal Signature. If so, the Full Name and Address of this individual must be reported on the blank spaces after the statement “Complete Only If Principal Is Physically Unable to Sign.” There will be a line labeled “Name,” “Street,” “City/Town,” and “State/Zip” provided for this purpose.

5 – The Principal Signature To This Document Should Be Substantiated By Witness Signature

The Principal is not the only one who must sign this form. In section 4, “Witness Statement” the two individuals who have observed the Principal signing this form must also sign their names to verify the act took place in a legal and ethical manner. First, the Date of Signature must be reported on the blank lines at the end of the “Witness Statement” paragraph. this should be reported as the two-digit Month, Day, and Year of the Witness Signing. It is standard practice that such signatures take place on the same day as the Principal Signing. Witness #1 and Witness #2 will each have his or her own column to Sign his or her Name, Print his or her Name, then report his or her Address.

6 – Each Individual Who Is Expected To Assume Decision Making Powers Must Acknowledge This By Signing It.

The next page will contain an Optional area. It is strongly recommended this page is completed and may only be done so by the Health Care Proxy or Health Care Agent and the Alternate Agent.

The Primary Health Care Agent will need to read the “Health Care Agent” acknowledgment statement, then sign his or her name on the line labeled “Signature of Health Care Agent.”The next paragraph, “Alternate Agent,” will also provide an acknowledgment statement but for the Alternate Health Care Agent. Here, the Alternate Health Care Agent will need to read the statement provided then sign his or her name on the blank line labeled “Signature of Alternate Agent.”

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