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Mass Health Care Proxy

Health Care Proxy Form (English)

Health Care Proxy Form (Spanish)

What is a Health Care Proxy?

A health care proxy is a document that allows you to name someone (your agent) to make health care decisions for you if you are in a situation where you cannot do this for yourself. Read the information below for instructions on how to fill out the health care proxy and for information on the Health Care Proxy Law (Massachusetts General Laws, Chapter 201D)

Who should have a Health Care Proxy?

Having a Health Care Proxy is like having insurance. You hope you don’t have to use it, but it is there if you need it. Any competent adult over the age of 18 may use this form to name a person they trust to speak for them (their Agent) should they become unable to make decisions or be unable to communicate their wishes regarding their medical care.

What does my Agent do?

Your Agent would only make decisions for you if you are unconscious or unable to communicate with your doctors and nurses. Your doctor must determine, in writing, that you are unable to make your own decisions. This gives your Agent authority to help your doctor make your medical decisions and guide your treatment.
In order to make the best decision, your Agent would have the right to review all of your medical information, including information on your diagnosis, prognosis, recommended treatments, and any necessary confidential information. Your Agent would make decisions for you based on his/her knowledge of your wishes. If your Agent is not sure of your wishes, they would make the decision which they believe to be in your best interest. It is important to discuss your wishes, including your moral and religious beliefs with your Agent so that he/she knows what is important to you. The decisions made by your Agent will be honored with the same authority as if you were making the decisions yourself. You may wish to speak with your doctor, pastor, family members, or others important to you, before giving your instructions to your Agent.

How to fill out the Health Care Proxy Form?

1.) Print your name and address and the name and address of the person you wish to appoint as your Agent. If you like, you can name a second person (Alternate Agent) in case the person you name is unable or unwilling to act as your behalf.

2.) You are allowed to list any limitations you want to make on your Agent’s ability to speak for you. You should consider this carefully, however, because it could make it difficult for your Agent to make decisions for you. You can leave this space blank if you do not wish to place any limits.

3.) Before you sign the paper, have two people with you who can witness your signature. Sign your name on the line. This gives your Agent your permission to act on your behalf. If you cannot sign your name, someone else can sign for you and fill out their name and address beneath the signature.

4.)Have your witnesses print their names and addresses on the back of the form.

5.) On the back of the form, there is also a place for your Agent and your Alternate Agent to sign statements that they are willing to act on your behalf. This side of the form is OPTIONAL. Your Health Care Proxy is still valid without their signatures.

You can change your Agent at any time by filling out a new form or by telling your doctor, other healthcare provider or someone else that you want to change your Proxy, or by destroying your form. If you legally separate from a spouse who has been your Agent, they are automatically no longer your Agent.

What to do with the form after it is filled out?

You should make at least four copies of the form. Keep the original yourself where it can be easily found if it is needed. Give copies to your doctor and ask to have a copy put into your medical record. You might want to give copies to your Agent and your Alternate Agent.

About Massachusetts Health Decisions

Massachusetts Health Decisions, a nonprofit serving the residents of Massachusetts for more than 30 years, has a website devoted to information about the Massachusetts Health Care Proxy and other issues about planning ahead for future health care. Please visit their site at: The Health Care Proxy form on the Holyoke Medical Center website has been published continuously for 30 years and will be accepted at any health care facility.

Information about the Proxy, for both patients and clinicians, is available in many languages including Spanish, Portuguese, American Sign Language, and a dozen other languages spoken in Massachusetts. If you have other questions, you can contact Massachusetts Health Decisions at any time at:

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Patient Rights & Responsibilities