Fillable Form 1: MASSACHUSETTS HEALTH CARE PROXY

Fill Online, Printable, Fillable, Blank Form 1: MASSACHUSETTS HEALTH CARE PROXY Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: MASSACHUSETTS HEALTH CARE PROXY

On average this form takes 12 minutes to complete

The Form 1: MASSACHUSETTS HEALTH CARE PROXY form is 2 pages long and contains:

  • 4 signatures
  • 0 check-boxes
  • 31 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
YOUR BIRTH DATE (m/d/y)
_____/_____/_____
MASSACHUSETTS HEALTH CARE PROXY
1
2
3
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 ____/____/____ ( mo / day / yr).
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.
Signed:____________________________________ Date: ___/___/___ (mo/day/yr)
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.
_______________________________________________________ _________________________________________________________
_________________________________________________________
(City/town) (State/ZIP)
(Name) (Street)
Witness #1 _____________________________
Name (print) ___________________________
Address _______________________________
______________________________________
(Signature)
Witness #2 _____________________________
Name (print) ___________________________
Address _______________________________
______________________________________
(Signature)
I, ___________________________________________________________________, residing at
___________________________________________________________________________________
appoint as my Health Care Agent: ____________________________________________________
of_________________________________________________________________________________
Agent’s tel (h) ____________________ (w) ____________________ E-mail __________________
OPTIONAL: If my agent is unwilling or unable to serve, then I appoint as my Alternate Agent:
______________________________________________________________________________________
of______________________________________________________________________________________
(Street) (City/town) (State/ZIP)
(Street) (City/town) (State/ZIP)
(Street) (City/town) (State/ZIP) (Phone)
(Name of person you choose as Agent)
(Name of person you choose as Alternate Agent)
(Principal: PRINT your name)
click to sign
signature
click to edit
click to sign
signature
click to edit
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. But 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. But 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)________________________________________________________
* * * * *
5
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: MASSACHUSETTS HEALTH CARE PROXY

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document