Massachusetts Health Care Proxy

HEALTH CARE PROXY

(General Laws of Massachusetts, Chapter 201D)

EXPLANATION

You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding anatomical gifts and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it.

Part 1 of this form is a Designation of Health Care Agent. Part 1 lets you name another individual as Agent to make health-care decisions for you if you become incapable of making your own decisions. You may also name an alternate Agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you.

Your Agent may make all health-care decisions for you, including decisions concerning providing, withholding or withdrawing of a life sustaining procedure.

PART 1: DESIGNATION OF HEALTH CARE AGENT

(1) DESIGNATION OF AGENT: I designate the following individual as my Agent to make health-care decisions for me:

Optional: If I revoke my Agent's authority or if my Agent is not willing, able, or reasonably available to make a health-care decision for me, I designate as my first alternate Agent:

Optional: If I revoke the authority of my Agent and first alternate Agent or if neither is willing, able, or reasonably available to make a health-care decision for me, I designate as my second alternate Agent:

(2) AGENT'S AUTHORITY: My Agent is authorized to make all health-care decisions for me, except as I state here:

I. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH.

A. General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to do all of the following: request, review and receive health information; execute releases; consent to disclosure; and consent to donation of organs for medical purposes.

B. HIPAA Release Authority. I authorize disclosure of my individually identifiable health information and medical records to my agent without restriction.

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:

My Agent's authority becomes effective when my primary physician determines I lack the capacity to make my own health-care decisions.

(4) AGENT'S OBLIGATION:

My Agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my Agent.

(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, check one:

PART 2: INSTRUCTIONS FOR HEALTH CARE

If you are satisfied to allow your Agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form.

(6) END-OF-LIFE DECISIONS: I direct that my health-care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

Choice Not To Prolong Life

I do not want my life to be prolonged if: (please check all that apply)

(i) I have a terminal condition.

(ii) I become permanently unconscious.

Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards.

RELIEF FROM PAIN: Except as I state in the following space, I direct treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

(7) OTHER MEDICAL INSTRUCTIONS:

PART 3: ANATOMICAL GIFTS AT DEATH

(OPTIONAL)

(8) I am mentally competent and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death.

I give:

my body;

any needed organs or parts;

the following organs or parts:

To the following person or institutions:

the physician in attendance at my death;

the hospital in which I die;

the following named physician, hospital, storage bank or other medical institution;

the following individual for treatment;

For the following purposes:

any purpose authorized by law;

transplantation;

therapy;

research;

medical education.

PART 4: PRIMARY PHYSICIAN

(OPTIONAL)

(9) I designate the following physician as my primary physician:

Optional: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my

Primary Physician shall mean a physician designated by an individual or the individual's Agent or guardian, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility.

(10) EFFECT OF COPY: A copy of this form has the same effect as the original.

(11) SIGNATURE: Sign and date the form here:

I understand the purpose and effect of this document.

(12) SIGNATURES OF WITNESSES:

Statement Of Witnesses

SIGNED AND DECLARED by the above-named declarant as and for his/her written Health Care Proxy pursuant to the General Laws of Massachusetts, Chapter 201D, who in his/her presence, at his/her request, and in the presence of each other, have hereunto subscribed our names as witnesses, and state and affirm: