Massachusetts Living Will Form
If you want to pre-determine the kinds of medical treatments you will receive at your end of life in the State of Massachusetts, the Massachusetts Living Will Form has to be completed and submitted.
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© Massachusetts Health Decisions 1999, Revised 2010 Licensed for use by the Massachusetts Medical Society MASSACHUSETTS HEALTH CARE PROXY BIRTH DATE ____/_____/____ 1. I,____________________________________________________________________________, residing at (Principal – PRINT your name) ____________________________________________________________________________________________ (Street) (City or town) (State) Appoint as my Health Care Agent:________________________________________________________________ (Name of person you choose as Agent) of _________________________________________________________________________________________ (Street) (City/town) (State) (Phone) OPTIONAL: If my Agent is unwilling to serve, then I appoint as my Alternate Agent: _________________________________________________________________________________________of (Name of person you choose as Alternate Agent) _______________________________________________________________________________________________________________________________________ (Street) (City/town) (State) (Phone) 2. My Agent shall have the authority to make all health care decisions for me, including decisions about life-sustaining treatment, subject to any limitations I state below, if I am unable to make health care decisions myself. My Agent's authority becomes effective if my attending physician determines in writing that I lack the capacity to make or to communicate health care decisions. My Agent is then to have the same authority to make health care decisions as I would if I had the capacity to make them EXCEPT (here list the limitations, if any, you wish to place on your Agent's authority): I direct my Agent to make health care decisions based on my Agent's assessment of my personal wishes. If my personal wishes are unknown, my Agent is to make health care decisions based on my Agent's assessment of my best interests. Photocopies of this Health Care Proxy shall have the same force and effect as the original and may be given to other health care providers. 3. Signed: _____________________________________________________________________________________ Complete only if Principal is physically unable to sign: I have signed the Principal's name above at his/her direction in the presence of the Principal and two witnesses. ________________________________________________________________________________________________ (Name) (Street) _____________________________________________ (City/town) (State) 4. WITNESS STATEMENT: We, the undersigned, each witnessed the signing of this Health Care Proxy by the Principal or at the direction of the Principal and state that the Principal appears to be at least 18 years of age, of sound mind and under no constraint or undue influence. Neither of us is named as the Health Care Agent or Alternate Agent in this document. In our presence, on this _____________day of __________________, 20_____ Witness #1_____________________________________Witness #2___________________________________ (Signature) Name (print)___________________________________Name (print)_________________________________ Address_______________________________________Address_____________________________________ _______________________________________ _____________________________________ © Massachusetts Health Decisions 1999, Revised 2010 Licensed for use by the Massachusetts Medical Society 5. Statements of Health Care Agent and Alternate Agent (OPTIONAL) Health Care Agent: I have been named by the Principal as the Principal's Health Care Agent by this Health Care Proxy. I have read this document carefully, and have personally discussed with the Principal his/her health care wishes at a time of possible incapacity. I know the Principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health facility where the Principal is presently a patient or resident or has applied for admission. Or if I am a person so described, I am also related to the Principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the Principal's wishes. (Signature of Health Care Agent) _________________________________________________________________ Alternate Agent: I have been named by the Principal as the Principal's Alternate Agent by this Health Care Proxy. I have read this document carefully, and have personally discussed with the Principal his/her health care wishes at a time of possible incapacity. I know the Principal and accept this appointment freely. I am not an operator, administrator or employee of a hospital, clinic, nursing home, rest home, Soldiers Home or other health facility where the Principal is presently a patient or resident or has applied for admission. Or if I am a person so described, I am also related to the Principal by blood, marriage, or adoption. If called upon and to the best of my ability, I will try to carry out the Principal's wishes. (Signature of Alternate Agent) ___________________________________________________________________ Model Health Care Proxy form developed by a Task Force of the following organizations: Boston University Schools of Medicine and Public Health: Law, Medicine, and Ethics Program Deaconess ElderCare Program Hospice Federation of Massachusetts Massachusetts Bar Association Massachusetts Department of Public Health Massachusetts Executive Office of Elder Affairs Massachusetts Federation of Nursing Homes Massachusetts Health Decisions Massachusetts Hospital Association Massachusetts Medical Society Massachusetts Nurses Association Medical Center of Central Massachusetts Suffolk University Law School: Elder Law Clinic University of Massachusetts at Boston: The Gerontology Institute Visiting Nurse Associations of Massachusetts Providers: For prices and information on quantity orders or for non-English language licensing, please contact Massachusetts Health Decisions, PO Box 417, Sharon, MA 02067 rev. 11/2010
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