The following is an example of the Massachusetts Health Care Proxy.

SECTION 1 INSTRUCTIONS
Print your full name and address. Print the name, address, and phone number of the person you choose as your Health Care Agent. (Optional: If you think your Agent might not be available at any future time, you may name a second person as an Alternate Agent.)

SECTION 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):

SECTION 2 INSTRUCTIONS
Setting limits on your Agent's authority might make it difficult for your Agent to act for you in an unexpected situation. If you want your Agent to have full authority to act for you, leave the limitations space blank. However, if you want to limit the kinds of decisions you would want your Agent or Alternate Agent to make for you, include them in the blank.

SECTION 3
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.

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:___________________________________________________________

Address:_________________________________________________________

SECTION 3 INSTRUCTIONS
BEFORE you sign, be sure you have two adults present who can witness you signing the document. The only people who cannot serve as witnesses are your Agent and Alternate Agent. Then sign the document yourself. (Or, if you are physically unable, have someone other than either witness sign your name at your direction. The person who signs your name for you should put his/her own name and address in the spaces provided.)

SECTION 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 this_____ day of_____________ , (date)______.

Witness #1______________________________________________(Signature)

Name (print)______________________________________________________

Address:_________________________________________________________

Witness #2______________________________________________(Signature)

Name (print)______________________________________________________

Address:_________________________________________________________

SECTION 4 INSTRUCTIONS
Have your witnesses fill in the date, sign their names and print their names and addresses.

SECTION 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)_______________________________________

SECTION 5 INSTRUCTIONS
OPTIONAL: On the back of the form are statements to be signed by your Agent and any Alternate Agent. This is not required by law, but is recommended to ensure that you have talked with the person or persons who may have to make important decisions about your care and that each of them realizes the importance of the task they may have to do.

Notice: This form is protected by federal copyright law and may be photocopied or reproduced only by the end user for his or her personal use. Health care organizations, professionals, and others can purchase the form in quantity from Massachusetts Health Decisions, the non-profit publisher of the form and educational materials related to the Massachusetts Health Care Proxy. The form is available in English and nine other languages. A complete information packet including two copies of the form, a basic brochure and a 16 page "User's Guide" in question and answer format is available for $6 postpaid. Please contact: Massachusetts Health Decisions, PO Box 417, Sharon, MA 02067.

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