Massachusetts Health Care Proxy Instructions and Document
Instructions to Complete the Fillable PDF Health Care Proxy
Every competent adult, 18 years old and older, has the right to appoint a Health Care Agent in a Health Care



1. Your Name and Full Address (Required)

2. My Health Care Agent is: (Required)

• 

• 


3. My Alternate Health Care Agent (Not required, but helpful to have an Alternate Agent)



4. My Health Care Agent’s Authority (Required)


• 
• 

STOP HERE. 

5. Signature and Date (Required)

• 
6. Witness Statement and Signature (Required)




• 
• 
7. Health Care Agent Statement (Optional)


Important



Massachusetts Health Care Proxy
1. I, ,
Address:
ap



2. My Health Care Agent is:

Address:
  
3. My Alternate Health Care Agent



  
4. My Health Care Agent’s Authority
I






5. Signature and Date

 ___________________________________________________________________________  _________________________
6. Witness Statement and Signature



Witness One
 ______________________________________________
 _________________________________________
 _________________________________________________
Witness Two
 ______________________________________________
 _________________________________________
 _________________________________________________
7. Health Care Agent Statement (Optional):

Health Care Agent _________________________________________________________________  _________________________
Alternate Health Care Agent _____________________________________________________  _________________________