Massachusetts Medical Power of Attorney Document

This Massachusetts Medical Power of Attorney (hereafter referred to as "Document") is designed in accordance with the Massachusetts Health Care Proxy Law (M.G.L. Chapter 201D) to enable individuals to appoint a Health Care Agent to make health care decisions on their behalf should they become unable to make such decisions for themselves.

1. Principal Information

Name: _______________________________________________

Address: ____________________________________________

City, State, ZIP: ____________________________________

Date of Birth: ______________________________________

Social Security Number: _____________________________

2. Health Care Agent Information

Name: _______________________________________________

Address: ____________________________________________

City, State, ZIP: ____________________________________

Primary Phone Number: _______________________________

Alternate Phone Number: _____________________________

3. Powers Granted to Health Care Agent

In accordance with the Massachusetts Health Care Proxy Law, I hereby appoint the above-named Health Care Agent to make any and all health care decisions for me, including decisions to refuse or consent to treatment, to the extent I could make such decisions for myself if I were capable of doing so. This grant of power is subject to any statements or limitations provided herein.

4. Special Instructions/Limitations

(Specify any particular desires, stipulations, or limitations concerning the health care decisions to be made on your behalf. Attach additional sheets if necessary.)

________________________________________________________________

________________________________________________________________

5. Replacement Agent (Optional)

In the event that my initially appointed Health Care Agent is unwilling, unavailable, or legally ineligible to act as my Health Care Agent, I hereby designate the following individual as my Replacement Agent:

Name: _______________________________________________

Address: ____________________________________________

City, State, ZIP: ____________________________________

Primary Phone Number: _______________________________

Alternate Phone Number: _____________________________

6. Duration

This Document shall remain in effect indefinitely from the date of its execution, unless I specify an expiration date or condition below:

Expiration Date or Condition: _________________________

7. Signatures

This Document is executed on this ____ day of _______________, 20____.

Principal Signature: _________________________________

Printed Name: ______________________________________

Witness Signature: __________________________________

Printed Name: ______________________________________

Address: ____________________________________________

City, State, ZIP: ____________________________________

Witness Declaration:

I declare that the principal appears to be of sound mind and under no duress, fraud, or undue influence. I am not the appointed Health Care Agent or the Replacement Agent. I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon their decease under a will now existing or by operation of law.