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Massachusetts : ___________________________________ 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 Massachusetts