The Massachusetts Medical Power of Attorney, better known as the “Health Care Proxy”, is the appointment of an agent to handle medical decisions on the behalf of another. The purpose of executing this document is to ensure that you are taking care of by a person of trust in the event of your incapacitation (the inability to function and vocalize your own wishes). This can be accomplished by providing the form with the details of both parties, listing any limitations/instructions regarding the authority, and signing it along with two (2) attesting individuals.
Laws
Statutes – Chapter 201D: Health Care Proxies
Definition – ”Health care proxy”, a document delegating to an agent the authority to make health care decisions, executed in accordance with the requirements of this chapter (201D § 1).
Signing Requirements – Acknowledgment of Two (2) Witnesses (201D § 2)
Revocation – 201D § 7
Other Versions (5)
- Baystate Health
- Central Mass. Partnership to Improve Care at the End of Life
- Dana-Farber Cancer Institute
- Honoring Choices Massachusetts
- Massachusetts Medical Society
Download: Adobe PDF
Central Mass. Partnership to Improve Care at the End of Life Version
Download: Adobe PDF
Dana-Farber Cancer Institute Version
Download: Adobe PDF
Honoring Choices Massachusetts Version
Download: Adobe PDF
Massachusetts Medical Society Version
Download: Adobe PDF
Multilingual Versions (9)
- Albanian
- Arabic
- Haitian Creole
- Khmer
- Portuguese
- Russian
- Spanish/Español
- Traditional Chinese
- Vietnamese
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Download: Adobe PDF
Additional Resources
- Honoring Choices Massachusetts – Choosing a Health Care Agent
- Honoring Choices Massachusetts – Things to Know About a Health Care Proxy
- Honoring Choices Massachusetts – Who’s Your Agent?
- Massachusetts Medical Society – Planning Ahead Brochure (Spanish/Español)
- Tufts Health Plan – Types of Advance Directives for Massachusetts
Related Forms
Advance Directive (Medical POA & Living Will)
Download: Adobe PDF
Comfort Care DNR Order Verification with Bracelet Inserts
Download: Adobe PDF
Durable (Financial) Power of Attorney
Download: Adobe PDF, MS Word (.docx)
Medical Orders for Life-Sustaining Treatment (MOLST) Form
Download: Adobe PDF, MS Word (.docx)
Information: Adobe PDF