MAKE YOUR FREE Massachusetts Medical Power of Attorney

INFORMATION CONCERNING THE HEALTH CARE PROXY

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS:

Except to the extent you state otherwise, this document gives the person you name as your Agent the authority to make MOST health care decisions for you if you cannot make the decisions for yourself. You may include specific limitations in this document on the authority of your Agent to make health care decisions for you.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so. In addition, after you have signed this document, no treatment may be given to you or stopped over your objection if you are mentally competent to make that decision.

You should inform the person you appoint that you want the person to be your Health Care Agent. You may state in this document any type of treatment that you do not desire and any that you want to make sure you receive. You should discuss this document and your wishes, values and preferences regarding your health care with your Agent.

Your Agent is obligated to follow your desires or if your desires are unknown, to act in your best interest. Your Agent is not liable for health care decisions made in good faith on your behalf. Unless you state otherwise, your Agent has the same authority to make decisions about your health care as you would have had. A physician must comply with your Agent's instructions or allow you to be transferred to another physician.

The person you appoint as your Agent should be someone you know and trust. The person must be an adult. Generally you cannot appoint your health or residential care provider (e.g., your physician or an employee of a home health agency, hospital, nursing home, or residential care home) to be your Agent, unless that person is related to you.

You may wish to designate an Alternate Agent in the event that your Agent is unwilling, unable, or ineligible to act as your Agent. Any Alternate Agent you designate has the same authority to make health care decisions for you.

You have the right to revoke the authority granted to your Agent by informing your Agent or your health or residential care provider orally or in writing, or by your execution of a subsequent durable power of attorney for health care. Unless you state otherwise, generally your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the document, you must make an entirely new one.

It is important that you discuss this document with your physician or other health care provider before you sign it to make sure that you understand the nature and range of decisions that may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions.

You should keep a copy of this document after you have signed it. Give a copy to the person you name as your Agent or alternate. You should indicate on the document itself the people and institutions who have signed copies. If you are in a health care facility, a copy of this document should be included in your medical record.

You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

HEALTH CARE PROXY

. DESIGNATION OF HEALTH CARE AGENT. I, , of , , appoint:

as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.

NOTICE: Generally you should not appoint any of the following persons as your Agent:

(1) your treating physician or health care provider;

(2) an employee of your physician or health care provider unless the person is your relative;

(3) your residential care provider; or

(4) an employee of your residential care provider unless the person is your relative.

. CREATION OF HEALTH CARE PROXY. By this document I intend to create a Health Care Proxy. This document shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.

. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, the authority to direct the withdrawal and withholding of artificially provided food and fluids.

In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests.

. GENERAL PROVISIONS.

1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.

2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.

(YOU MUST DATE AND SIGN THIS DOCUMENT

IN THE PRESENCE OF TWO WITNESSES)

I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.

Signed on ______ day of ____________________, _____.

STATEMENT OF WITNESSES

I declare that the person who signed or acknowledged this document, , (the "Principal") has identified himself or herself to me, that signed or acknowledged this document in my presence, that appears to be of sound mind, and under no duress, fraud or undue influence, and at least eighteen years of age. I am not the person appointed as Agent or Alternate Agent by this document, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.

I further declare that I am not related to by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of or entitled to any part of the estate of under a will now existing or by operation of law. I am at least eighteen years of age.

Date: _________________________

Date: _________________________