The Massachusetts Medical Power of Attorney, better known as the “Health Care Proxy”, is the appointment of an agent to handle medical decisions on the behalf of another. The purpose of executing this document is to ensure that you are taking care of by a person of trust in the event of your incapacitation (the inability to function and vocalize your own wishes). This can be accomplished by providing the form with the details of both parties, listing any limitations/instructions regarding the authority, and signing it along with two (2) attesting individuals.

Other Versions (5)

• Baystate Health
• Central Mass. Partnership to Improve Care at the End of Life
• Dana-Farber Cancer Institute
• Honoring Choices Massachusetts
• Massachusetts Medical Society

Baystate Health Version

Download: Adobe PDF

 

 

 

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Central Mass. Partnership to Improve Care at the End of Life Version

Download: Adobe PDF

 

 

 

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Dana-Farber Cancer Institute Version

Download: Adobe PDF

 

 

 

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Honoring Choices Massachusetts Version

Download: Adobe PDF

 

 

 

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Massachusetts Medical Society Version

Download: Adobe PDF

 

 

 

Multilingual Versions (9)

• Albanian
• Arabic
• Haitian Creole
• Khmer
• Portuguese
• Russian
• Spanish/Español
• Traditional Chinese
• Vietnamese

Albanian Version

Download: Adobe PDF

 

 

 

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Arabic Version

Download: Adobe PDF

 

 

 

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Haitian Creole Version

Download: Adobe PDF

 

 

 

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Khmer Version

Download: Adobe PDF

 

 

 

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Portuguese Version

Download: Adobe PDF

 

 

 

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Russian Version

Download: Adobe PDF

 

 

 

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Spanish/Español Version

Download: Adobe PDF

 

 

 

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Traditional Chinese Version

Download: Adobe PDF

 

 

 

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Vietnamese Version

Download: Adobe PDF

 

 

 

Additional Resources

• Honoring Choices Massachusetts – Choosing a Health Care Agent
• Honoring Choices Massachusetts – Things to Know About a Health Care Proxy
• Honoring Choices Massachusetts – Who’s Your Agent?
• Massachusetts Medical Society – Planning Ahead Brochure (Spanish/Español)
• Tufts Health Plan – Types of Advance Directives for Massachusetts

Related Forms

Advance Directive (Medical POA & Living Will)

Download: Adobe PDF

 

 

 

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Comfort Care DNR Order Verification with Bracelet Inserts

Download: Adobe PDF

 

 

 

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Durable (Financial) Power of Attorney

Download: Adobe PDF, MS Word (.docx)

 

 

 

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Medical Orders for Life-Sustaining Treatment (MOLST) Form

Download: Adobe PDF, MS Word (.docx)
Information: Adobe PDF