Massachusetts Health Care Proxy

Choose a primary and alternate agent

The Massachusetts proxy appoints one health care agent and an alternate who can serve when the first person is unavailable. It gives the agent broad health care authority, subject to limitations you write into the form. The agent must use your known wishes, including religious and moral beliefs, and your best interests when your wishes are not known.

Sources: [1] [2] [3]

Discuss limits and access to information

The form allows the agent to receive medical information and gives photocopies the same effect as the original. Write any intended treatment limits in the supplied space and discuss them with your agent and clinician. Your agent’s authority under this form begins with the attending physician’s incapacity determination; completing the proxy does not remove your own ability to make decisions while capable.

Sources: [1] [2] [3]

Keep both pages together

The principal signs on the first page, while the witnesses sign on the second. Use witnesses who are not the agent or alternate. The second page also contains optional acceptance signatures for those appointees; the packet distinguishes these from its required execution steps. The state-hosted PDF is marked 12/03, so its hosting date is not a revision date. Give the complete signed proxy to your agent, alternate, and care providers.

Sources: [1] [2] [3]

Related forms and guides

• Massachusetts Power of Attorney Forms
• Massachusetts General Durable Power of Attorney
• Medical Power of Attorney and Health Care Proxy Forms
• Medical vs. Financial Power of Attorney

Sources and verification

1. Central Massachusetts Partnership to Improve Care at the End of Life; hosted by Mass.gov: source and instructions ↗ (opens in a new tab)
2. Signing and legal requirements ↗ (opens in a new tab)
3. Authority and statutory guidance ↗ (opens in a new tab)

HTTP200, two-page PDF downloaded and inspected; printed edition12/03. No claim that the older printed form was revised in2026.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.