This Massachusetts Medical Power of Attorney is a legal document that allows an individual (the "Principal") to designate a trusted person (the "Agent") to make healthcare decisions on their behalf, should they become incapable of making such decisions themselves. This document is prepared in accordance with the Massachusetts Health Care Proxy Law (Massachusetts General Laws, Chapter 201D).
Please Note: This template is designed to provide general guidelines and should be used as a reference. It may not suit all situations. For specific legal advice or concerns, please consult an attorney.
Principal Information:
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: _____________________________
Agent Information:
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone: _______________________
- Alternate Phone: _____________________
- Email Address: _______________________
Alternate Agent Information: (Optional)
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone: _______________________
- Alternate Phone: _____________________
- Email Address: _______________________
In the event that the above-named Agent is unable, unwilling, or unavailable to act as my Medical Power of Attorney, I hereby designate the following individual as my Alternate Agent.
Special Instructions:
Please specify any limitations, special instructions, or preferences regarding medical treatment that the Agent should consider while making health care decisions on your behalf. (e.g., preferences concerning life-sustained treatments, religious considerations, etc.)
________________________________________________________________________________
________________________________________________________________________________
*By signing this document, the Principal affirms their understanding and agreement to appoint the named individual(s) as their Agent(s) to make healthcare decisions on their behalf under the Massachusetts Health Care Proxy Law. This document grants the Agent authority only when the Principal cannot make or communicate health care decisions themselves.
Signature of Principal: __________________________ Date: ________________
Signature of Agent: _____________________________ Date: ________________
Signature of Alternate Agent: ____________________ Date: ________________ (Optional)
Witness Statement: We, the undersigned, declare that the Principal appears to be of sound mind and free of duress or undue influence at the time of signing this document.
- Witness 1 Signature: _______________________________ Date: ________________
- Print Name: ________________________________________
- Witness 2 Signature: _______________________________ Date: ________________
- Print Name: ________________________________________