A Massachusetts advance directive is a legal document that an adult in Massachusetts can use to appoint a healthcare agent. The form legally authorizes this designated person to make healthcare-related decisions on behalf of the principal. This can be useful in situations of severe illness or injury.
Sample
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Massachusetts Health Care Proxy
I, [NAME], of [ADDRESS, STREET, CITY, STATE, ZIP CODE],
appoint the following person to be my Health Care Agent with the authority to make health care decisions on my behalf. This authority becomes effective if my attending physician determines in writing that I lack the capacity to make or communicate health care decisions myself, according to Chapter 201D of the General Laws of Massachusetts.
2. My Health Care Agent is:
Name: [NAME]
Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]
Phone(s): [HOME PHONE]; [MOBILE PHONE]; [WORK PHONE]
3. My Alternate Health Care Agent
If my Agent is not available, willing or competent, or not expected to make a timely decision, I appoint:
Name: [NAME]
Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]
Phone(s): [HOME PHONE]; [MOBILE PHONE]; [WORK PHONE]
4. My Health Care Agent’s Authority
I give my Health Care Agent the same authority I have to make any and all health care decisions including life-sustaining treatment decisions, except:
[LIST LIMITS TO AUTHORITY OR GIVE INSTRUCTIONS, IF ANY].
I authorize my Health Care Agent to make health care decisions based on his or her assessment of my choices, values and beliefs if known, and in my best interest if not known. I give my Health Care Agent the same rights I have to the use and disclosure of my health information and medical records as governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d. Photocopies of this Health Care Proxy have the same force and effect as the original.
5. Signature and Date. I sign my name and date this Health Care Proxy in the presence of two witnesses.
SIGNED ________________________________________________________
DATE [DAY] day of [MONTH], 20[XX]
6. Witness Statement and Signature We, the undersigned, have witnessed the signing of this document by or at the direction of the signatory above and state the signatory appears to be at least 18 years old, of sound mind and under no constraint or undue influence. Neither of us is the health care agent or alternate agent.
Signed: ________________________________________________________
Print Name: _____________________________________________________
Date: [DAY] day of [MONTH], 20[XX]
Signed: ________________________________________________________
Print Name: _____________________________________________________
Date: [DAY] day of [MONTH], 20[XX]
7. Health Care Agent Statement (Optional): We have read this document carefully and accept the appointment.
Health Care Agent ________________________________________________
Date [DAY] day of [MONTH], 20[XX]
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