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This Health Care Proxy Form was prepared by The Central Massachusetts Partnership to Improve Care at the End of Life. The Partnership grants permission to reproduce this document in its entirety, so long as the source, including this statement, is shown.
This Health Care Proxy document, provided free of charge, gives a clear explanation of the responsibilities of a health care agent, and simple directions on how fill out and sign the form. There are also instructions on how to revoke or cancel the document at a later date, if you choose to do so.
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.
To create your Health Care Proxy, print this two page form and place the instructions page and the blank document in front of you. Follow the step-by-step instructions and sign and date the Health Care Proxy in front of two witnesses, who sign and date the document after you.
MASSACHUSETTS HEALTH CARE PROXY. OU. B. ____/____/____ 1. I, (Principal -- PRINT your name) , residing at. (Street) appoint as my Health Care Agent: (City or Town) (Name of person you choose as Agent) (State) of. (Street) (City/town) (State) (Phone) . ( OPTIONAL: If my Agent is unwilling or unable to serve, then I appoint as my Alternate Agent:
The Massachusetts Health Care Proxy form can be downloaded and printed out here. If you need another copy, your physician, nurse, social worker, or someone from pastoral care at the medical center can get you one.
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.
