	Massachusetts Medical Power of Attorney Form
	Email PDF Adobe PDF

The Massachusetts medical power of attorney form is a legal document that would allow a Principal to appoint an Agent that they would trust, to make health care decisions on their behalf in the event, for any reason, the Principal should become unable to make or communicate their own health care decisions. Due to the fact that this document concerns not only the choices the Principal would choose to make make over their own health care, as well the relationships the Principal would have with their family, physician or anyone else who may be involved with the Principal’s health care. The document should be carefully reviewed by the Principal to ensure that they understand the document they are signing. If it’s unclear, the Principal may wish to contact and consult with an attorney to answer any question for them prior to signing the document.

The Principal may revoke this document at their discretion, This document will require that two (2) witnesses are present to witness the Principal’s signing of the document.

How to Write

Step 1 – Download the document – The Principal must read through the titled sections as follows:

What does the Health Care Proxy Law allow?
What can my Agent do?
Who should have the original and copies?
How can I revoke or cancel the document?

Step 2 – The Parties –

In the top right corner, enter the Principal’ date of birth in mm/dd/yyyy format
Print the name of the Principal
Enter the Address
City
State
Zip Code
AND
Agent’s name
Street address
City
State
Zip Code
Telephone number
Home Phone
Work Phone
Email address
AND

In the event the original agent can no longer serve –

Alternate Agent’s name (optional)
Street Address
City
State
Zip Code
Telephone Number

Step 3 – Exceptions –

Should the Principal wish to impose limitations or exceptions, type or write them into the space provided

Step 4 – Signatures –

Signature of Principal
Date signature in mm/dd/yyyy format
In the event the Principal is unable to sign the document enter the information regarding who is signing on the Principal’s behalf
Name of the signatory
Street Address
City
State
Zip Code

Step 5 – Witness Statements – Each witness must read the statement. If in agreement, each agent must enter:

Witnesses Signatures
Witnesses Printed Names
Full Physical Address

Step 6 – Statements of Health Care Agent and Alternate Agent (Optional) – Both the Agent and Alternate Agent must read their respective paragraphs and provide:

Signature of Health Care Agent
Signature of Alternate Agent

Massachusetts Medical Power of Attorney Form

Massachusetts Medical Power of Attorney Form

How to Write

Related Forms