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Massachusetts ________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- his _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me t_ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: _______________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: __________________________________acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at ___________________l not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while le Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shal third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this Durabto a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the(a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of my Agent; and/or (c) my assets to be subject er-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are limited to the extent necessary to prevent fected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this powrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaf and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restn for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handledentitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensatioe and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. My Agent shall be on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receivin writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. This Power of Attorney shall not terminate rectly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my subsequent disability or incapacity as certified any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, if the result is that the disclaimed assets pass diust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from ions, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trof appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligatassign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers ar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendt tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers angible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gifncy, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, ther governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any ageited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or otess that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limcontents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. 12. To maintain and/or operate any businosit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the orm any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. -2- 10. To have access to any safe depuments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perfusiness with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instrhecking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any banyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, c any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and performppropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension,y reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other a may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me b(now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own orest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible le, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvts, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due in the future, owned by, due, owing payabst any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposik, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf againases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, asal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawry to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deall lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessaause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and l, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or c act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or persona___________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ maintaining an address at: ____________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-inLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _____________________________________revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- DURABbinding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may al matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of attorney document, is legally of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legic. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specifcord, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, if the Agent will deal with eal property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public reis unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any r of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event the original Agent the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since this Durable Powernt and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especially important if n acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorney is a "powerful" instrumecipal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here to mean "lawyer". The perso allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalf, even if the Prinase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability A Durable Power of Attorneyhould only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with another party. [_] The purchserve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal advice. These forms susiness and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to serve or continue to he Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent has the power to handle bginal document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks t real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, Agent or Notary should not be a witness. [_] The Principal should keep the oriecord, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will be dealing with anyincipal. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recorded as a public rtion for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the Disability of the PrInstructions & Checklist Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) Informa MassachusettsMassachusetts of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow MassachusettsMassachusetts s Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ 2 e) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ _____________________________________________ (Witnesunder no duress, constraint or undue influence. He or she signed (or asked another to sign for him or her) this document in my presence. _____________________________________________ (Witness Signatur___________________________ Dated: ______________________________ Statement by Witnesses I declare that the person who signed this document appears to be at least 18 years of age, of sound mind, and in a new writing or by clearly indicating that I have changed my mind. Signed: ____________________________________________________________________ Address: ______________________________________________________________________________ 1 These directions express my legal right to refuse treatment under federal and state law. I intend my instructions to be carried out, unless I have revoked them ____ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ________________________________________________________________________ antibiotics. However, I do want maximum pain relief, even if it may hasten my death. Additional Instructions (optional - insert personal instructions or cross out if none): __________________________escribed above I feel very strongly about the following forms of treatment: · I do not want cardiac resuscitation. · I do not want mechanical respiration. · I do not want tube feeding. · I do not want including any pain that might occur by withholding or withdrawing treatment. Although I understand that I am not legally required to be specific about future treatments, if I am in the condition(s) d (3) a minimally conscious condition in which I am permanently unable to make decisions or express my wishes. I direct that treatment be limited to measures to keep me comfortable and to relieve pain,n incurable or irreversible mental or physical condition with no reasonable expectation of recovery, including but not limited to: (1) a terminal condition; (2) a permanently unconscious condition; ored commitment to decline medical treatment under the circumstances indicated below: I direct my attending physician to withhold or withdraw treatment that merely prolongs my dying, if I should be in aeing of sound mind, make this statement as a directive to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settlchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Choice In Dying / Living Will I, ___________________________________________________________, bom a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purfrom state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice frsuitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and this section shall immediately notify the attending physician of such revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their s known by the physician to be involved in the principal's care of the revocation. Any agent or member of the nursing staff informed of or provided with a revocation of a health care proxy pursuant tof or provided with a revocation of a health care proxy shall immediately record the revocation in the principal's medical record and notify orally and in writing the agent and any health care providerubsequent health care proxy, or (ii) the divorce or legal separation of the principal and his spouse, where the spouse is the principal's agent under a health care proxy. A physician who is informed ooke a health care proxy unless determined otherwise pursuant to court order. Information & Instructions ­ Page 5 A health care proxy shall also be revoked upon: (i) execution by the principal of a scare provider orally or in writing or by any other act evidencing a specific intent to revoke the proxy. For the purposes of this section, every principal shall be presumed to have the capacity to revhall be required. CHAPTER 201D. HEALTH CARE PROXIES. Section 7. Revocation of health care proxy; notification. Section 7. A principal may revoke a health care proxy by notifying the agent or a health hat the principal has regained capacity: (i) the authority of the agent shall cease, but shall recommence if the principal subsequently loses capacity; and (ii) the principal's consent for treatment sh care proxy the principal's decisions shall prevail unless the principal is determined to lack capacity to make health care decisions by court order. In the event the attending physician determines tnding a determination pursuant to this section that the principal lacks capacity to make health care decisions, where a principal objects to a health care decision made by an agent pursuant to a healtto this section that a principal lacks capacity to make health care decisions is solely for the purpose of empowering an agent to make health care decisions pursuant to a health care proxy. Notwithstaincipal's ability to comprehend such notice; (ii) to the agent; and (iii) if the patient is in or is transferred from a mental health facility, to the facility director. A determination made pursuant ns. Notice of a determination that a principal lacks capacity to make health care decisions shall promptly be given orally and in writing: (i) to the principal, where there is any indication of the pr the same or similar nature in making such determination. A physician who has been appointed as a patient's agent shall not make the determination of the patient's capacity to make health care decisiomakes the determination must have, or must consult with a health care professional who has, specialized training or experience in diagnosing or treating mental illness or developmental disabilities ofd into the principal's permanent medical record. If the attending physician determines that a patient lacks capacity because of mental illness or developmental disability, the attending physician who and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This written determination shall be entereons ­ Page 4 communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to Information & InstructiPROXIES. Section 6. Determination that principal lacks capacity to make or to communicate health care decisions; notice; objections to agent's decision; determination of regained capacity. Section 6. alth care proxy to the same extent as if such decisions have been made by the principal, subject to any limitations in the health care proxy, or in any specific court order. CHAPTER 201D. HEALTH CARE th care proxy shall arrange for the proxy or a copy thereof to be inserted in the principal's medical record. A health care provider shall comply with health care decisions made by an agent under a herney as would decisions by the principal, when competent, except as otherwise provided in the health care proxy or by specific court order overriding the proxy. A physician who is provided with a healsions by an agent pursuant to a health care proxy on a principal's behalf shall have the same priority over decisions by any other person, including a person acting pursuant to a durable power of attoion necessary to make informed decisions regarding the principal's health care, including any and all confidential medical information that the principal would be entitled to receive. Health care decirdance with the agent's assessment of the principal's best interests. Notwithstanding any general or special law to the contrary, the agent shall have the right to receive any and all medical informath care decisions: (i) in accordance with the agent's assessment of the principal's wishes, including the principal's religious and moral beliefs, or (ii) if the principal's wishes are unknown, in accor consultation with health care providers, and after full consideration of acceptable medical alternatives regarding diagnosis, prognosis, treatments and their side effects, the agent shall make healtcare decisions on the principal's behalf that the principal could make, including decisions about life-sustaining treatment, subject, however, to any express limitations in the health care proxy. AfteD. HEALTH CARE PROXIES. Section 5. Health care decisions; agents's right to medical information; priority of agent's decisions. Section 5. An agent shall have the authority to make any and all health authority; and (iv) indicate that the agent's authority shall become effective if it is determined pursuant to section six that the principal lacks capacity to make health care decisions. CHAPTER 201ve authority to make health care decisions on the principal's behalf; Information & Instructions ­ Page 3 (iii) describe the limitation, if any, that the principal intends to impose upon the agent's PROXIES. Section 4. Duties of health care proxy. Section 4. The health care proxy shall: (i) identify the principal and the health care agent; (ii) indicate that the principal intends the agent to haent of such facility or has applied for admission to such facility unless said operator, administrator or employee is related to the principal by blood, marriage or adoption. CHAPTER 201D. HEALTH CAREon 3. No person who is an operator, administrator or employee of a facility may be appointed as health care agent by an adult, who, at the time of executing the health care proxy is a patient or residrincipal's behalf pursuant to other requirements of this chapter. CHAPTER 201D. HEALTH CARE PROXIES. Section 3. Operators, administrators or employees of facilities; limitations on appointments. Secticare agent is not expected to become available, willing or competent to make a timely decision given the patient's medical circumstances; or, the health care agent is disqualified from acting on the pernate health care agent as part of a valid health care proxy. Said alternate may serve when the designated health care agent is not available, willing or competent to serve and the designated health section, every adult shall be presumed to be competent and every health care proxy shall be presumed to be properly executed unless a court determines otherwise. A competent adult may designate an altnd and under no constraint or undue influence. No person who has been named as health care agent in a health care proxy shall act as a witness to the execution of such proxy. For the purposes of this of two other adults who shall subscribe their names as witnesses to such signature. The witnesses shall affirm in writing that the principal appeared to be at least eighteen years of age, of sound mi shall have the right to appoint a health care agent by executing a health care proxy. Said health care proxy shall be in writing signed by such adult or at the direction of such adult in the presence a person who has executed a health care proxy. CHAPTER 201D. HEALTH CARE PROXIES. Section 2. Appointment of health care agents; health care proxies; alternate agents. Section 2. Every competent adultoxy'', a document delegating to an agent the authority to make health care decisions, executed in accordance with the requirements of this chapter. Information & Instructions ­ Page 2 ""Principal'',der'', an individual or facility licensed, certified, or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice. "Health care prwhich is made in accordance with the requirements of this chapter, is consistent with any limitations in the health care proxy, and is consistent with responsible medical practice. ""Health care provi agent'' or ""agent'', an adult to whom authority to make health care decisions is delegated under a health care proxy. ""Health care decision made by an agent under a health care proxy'', a decision s defined in section seventy E of chapter one hundred and eleven. ""Health care'', any treatment, service or procedure to diagnose or treat the physical or mental condition of a patient. ""Health care the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision. ""Facility'', any facility ad. Where more than one physician shares such responsibility, any such physician may act as the attending physician. ""Capacity to make health care decisions'', the ability to understand and appreciatehysician'', the physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendere01D. HEALTH CARE PROXIES. Section 1. Definitions. Section 1. As used in this chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:""Attending pl is based on the General Laws of Massachusetts Title II Chapter 201D. For your convenience, we have included useful excerpts from the General Laws of Massachusetts relating to Living Wills. CHAPTER 2Information and Instructions Massachusetts Living Will This package contains (1) Information and Instruction for Massachusetts Living Will; (2) Massachusetts Living Will. This Massachusetts Living Wil MassachusettsMassachusetts : ___________________________________ Address: ______________________________________ Date: _________________________________________ -2- ________________________ Address: ______________________________________ Date: _________________________________________ _____________________________________________ (Witness 2 Signature) Print Namer) this document in my presence. I am not the person appointed as agent or alternate agent by this document. _____________________________________________ (Witness 1 Signature) Print Name: ___________ the person who signed this document appears to be at least 18 years of age, of sound mind, and under no duress, constraint or undue influence. He or she signed (or asked another to sign for him or he_______________________________________ Address: ______________________________________________________________________ Dated: ______________________________ -1- Statement by Witnesses I declare that__ _____________________________________________________________________________ _____________________________________________________________________________ (5) Signed: _____________________________sions in accord with what he or she determines to be my best interests. (4) Other directions (optional ­ cross out if none): ___________________________________________________________________________ to make health care decisions in accord with my wishes and limitations as as may be stated below, or as he or she otherwise knows. If my wishes are unknown, I direct my agent to make health care deci___________________ (name of alternate agent) _____________________________________________________________________________ (home address and telephone number of alternate agent) (3) I direct my agentons. (2) Name of alternate agent if the person I appoint above is unable, unwilling or unavailable to act as my health care agent (optional): __________________________________________________________ health care decisions for me, except to the extent that I state otherwise below. This Health Care Proxy shall take effect in the event I become unable to make or communicate my own health care decisi_________________ (name of agent) _____________________________________________________________________________ (home address and telephone number of agent) as my health care agent to make any and alllforms.com -5- Massachusetts Health Care Proxy (1) I, ____________________________________________________________, hereby appoint (name) ____________________________________________________________ible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegag this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possdvice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signin been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax ation of a health care proxy pursuant to this section shall immediately notify the attending physician of such revocation. [_] These forms are provided "as is" and no implied or express warranties have the agent and any health care providers known by the physician to be involved in the principal's care of the revocation. Any agent or member of the nursing staff informed of or provided with a revocare proxy. A physician who is informed of or provided with a revocation of a health care proxy shall immediately record the revocation in the principal's medical record and notify orally and in writing: (i) execution by the principal of a subsequent health care proxy, or (ii) the divorce or legal separation of the principal and his spouse, where the spouse is the principal's agent under a health caf this section, every principal shall be presumed to have the capacity to revoke a health care proxy unless determined otherwise pursuant to court order. A health care proxy shall also be revoked uponipal may revoke a health care proxy by notifying the agent or a health care provider orally or in writing or by any other act evidencing a specific intent to revoke the proxy. -4- For the purposes ouently loses capacity; and (ii) the principal's consent for treatment shall be required. CHAPTER 201D. HEALTH CARE PROXIES. Section 7. Revocation of health care proxy; notification. Section 7. A princsions by court order. In the event the attending physician determines that the principal has regained capacity: (i) the authority of the agent shall cease, but shall recommence if the principal subseq objects to a health care decision made by an agent pursuant to a health care proxy the principal's decisions shall prevail unless the principal is determined to lack capacity to make health care deci make health care decisions pursuant to a health care proxy. Notwithstanding a determination pursuant to this section that the principal lacks capacity to make health care decisions, where a principalalth facility, to the facility director. A determination made pursuant to this section that a principal lacks capacity to make health care decisions is solely for the purpose of empowering an agent to writing: (i) to the principal, where there is any indication of the principal's ability to comprehend such notice; (ii) to the agent; and (iii) if the patient is in or is transferred from a mental hethe determination of the patient's capacity to make health care decisions. Notice of a determination that a principal lacks capacity to make health care decisions shall promptly be given orally and in diagnosing or treating mental illness or developmental disabilities of the same or similar nature in making such determination. A physician who has been appointed as a patient's agent shall not make ental illness or developmental disability, the attending physician who makes the determination must have, or must consult with a health care professional who has, specialized training or experience inxtent and probable duration. This written determination shall be entered into the principal's permanent medical record. If the attending physician determines that a patient lacks capacity because of md standards of medical judgment. The determination shall be in writing and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its e the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to acceptecare decisions; notice; objections to agent's decision; determination of regained capacity. -3- Section 6. The authority of a health care agent shall begin after a determination is made, pursuant toto any limitations in the health care proxy, or in any specific court order. CHAPTER 201D. HEALTH CARE PROXIES. Section 6. Determination that principal lacks capacity to make or to communicate health ical record. A health care provider shall comply with health care decisions made by an agent under a health care proxy to the same extent as if such decisions have been made by the principal, subject lth care proxy or by specific court order overriding the proxy. A physician who is provided with a health care proxy shall arrange for the proxy or a copy thereof to be inserted in the principal's medority over decisions by any other person, including a person acting pursuant to a durable power of attorney as would decisions by the principal, when competent, except as otherwise provided in the hea all confidential medical information that the principal would be entitled to receive. Health care decisions by an agent pursuant to a health care proxy on a principal's behalf shall have the same pri or special law to the contrary, the agent shall have the right to receive any and all medical information necessary to make informed decisions regarding the principal's health care, including any anding the principal's religious and moral beliefs, or (ii) if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's best interests. Notwithstanding any generalernatives regarding diagnosis, prognosis, treatments and their side effects, the agent shall make health care decisions: (i) in accordance with the agent's assessment of the principal's wishes, includ life-sustaining treatment, subject, however, to any express limitations in the health care proxy. After consultation with health care providers, and after full consideration of acceptable medical altpriority of agent's decisions. Section 5. An agent shall have the authority to make any and all health care decisions on the principal's behalf that the principal could make, including decisions abouted pursuant to section six that the principal lacks capacity to make health care decisions. CHAPTER 201D. HEALTH CARE PROXIES. Section 5. Health care decisions; agents's right to medical information; 's behalf; (iii) describe the limitation, if any, that the principal intends to impose upon the agent's authority; and (iv) indicate that the agent's authority shall become effective if it is determinhealth care proxy shall: (i) identify the principal and the health care agent; -2- (ii) indicate that the principal intends the agent to have authority to make health care decisions on the principaly unless said operator, administrator or employee is related to the principal by blood, marriage or adoption. CHAPTER 201D. HEALTH CARE PROXIES. Section 4. Duties of health care proxy. Section 4. The a facility may be appointed as health care agent by an adult, who, at the time of executing the health care proxy is a patient or resident of such facility or has applied for admission to such facilit CHAPTER 201D. HEALTH CARE PROXIES. Section 3. Operators, administrators or employees of facilities; limitations on appointments. Section 3. No person who is an operator, administrator or employee of ent to make a timely decision given the patient's medical circumstances; or, the health care agent is disqualified from acting on the principal's behalf pursuant to other requirements of this chapter.id alternate may serve when the designated health care agent is not available, willing or competent to serve and the designated health care agent is not expected to become available, willing or compethealth care proxy shall be presumed to be properly executed unless a court determines otherwise. A competent adult may designate an alternate health care agent as part of a valid health care proxy. Sabeen named as health care agent in a health care proxy shall act as a witness to the execution of such proxy. For the purposes of this section, every adult shall be presumed to be competent and every to such signature. The witnesses shall 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. No person who has a health care proxy. 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 witnessesLTH CARE PROXIES. Section 2. Appointment of health care agents; health care proxies; alternate agents. Section 2. Every competent adult shall have the right to appoint a health care agent by executingg to an agent the authority to make health care decisions, executed in accordance with the requirements of this chapter. ""Principal'', a person who has executed a health care proxy. CHAPTER 201D. HEAlicensed, certified, or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice. -1- "Health care proxy'', a document delegatinthe requirements of this chapter, is consistent with any limitations in the health care proxy, and is consistent with responsible medical practice. ""Health care provider'', an individual or facility o whom authority to make health care decisions is delegated under a health care proxy. ""Health care decision made by an agent under a health care proxy'', a decision which is made in accordance with chapter one hundred and eleven. ""Health care'', any treatment, service or procedure to diagnose or treat the physical or mental condition of a patient. ""Health care agent'' or ""agent'', an adult tealth care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision. ""Facility'', any facility as defined in section seventy E ofshares such responsibility, any such physician may act as the attending physician. ""Capacity to make health care decisions'', the ability to understand and appreciate the nature and consequences of hed by or assigned to a patient, who has primary responsibility for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician 1. Definitions. Section 1. As used in this chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:""Attending physician'', the physician, selectLaws of Massachusetts Title II Chapter 201D. The following are useful excerpts from the General Laws of Massachusetts relating to the Health Care Proxy Form. CHAPTER 201D. HEALTH CARE PROXIES. Sectionorney for Health Care) ; (2) Massachusetts Health Care Proxy (Power of Attorney for Health Care) Form. This Massachusetts Health Care Proxy (Power of Attorney for Health Care) is based on the General Information and Instructions Massachusetts Health Care Proxy (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Massachusetts Health Care Proxy (Power of Att MassachusettsMassachusetts _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y MassachusettsMassachusetts ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa MassachusettsMassachusetts _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Massachusetts