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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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