The first section, the living will, will be used to specify the conditions under which the principal does or does not consent to the various critical lifesaving medical treatments. The health care proxy statute provides the legal ability for the family and others to take over someones health decisions if the incapacitated person is. Instructions to complete the fillable pdf health care proxy. Free massachusetts health care proxy medical poa form. You can use the instructions as a checklist as you fill out the form. I direct that my agent to make any and all health care decisions according to my instructions as. The health care proxy is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason. Your rights to make health care decisions connecticut. By providing these forms and information, everplans is not providing legal advice to you. Health care proxy appointing your health care agent in new. Proxy directive durable power of attorney for health care pdf 15k.
In a health care power of attorney or health care proxy you select the family member or trusted friend you want to make health care decisions for you when you. Important information about health care proxy forms in massachusetts. Every adult, 18 years and old, or their health care agent and guardian, has the right to be fully informed about their health care to make choices for care that reflect each individuals care goals, values and priorities. The new jersey commission on legal and ethical problems in the delivery of health care page 1 of 2 proxy directivedurable power of attorney for health care designation of health care representative i understand that as a competent adult, i have the right to make decisions about my health care. Free florida medical power of attorney form pdf eforms. The probate and family court department procedure for. Massachusetts law about health care proxies and living wills. The document can be useful to have in place in the event you are incapacitated in an accident or otherwise and cant communicate your wishes with your. To create your health care proxy, print this two page form and place the instructions page and the blank document in front of you. To create a valid massachusetts health care proxy, first, print this document so you have the instructions and the blank form in front of you.
Subject to any restrictions set forth in section 5 below, i grant to my health care agent full power and authority to make and carry out all health care decisions for me. Health care proxy form and instructions honoring choices. This form is being provided to you as a public service. Please bring a copy of your living will and health care proxy with you to all hospital appointments for surgical procedures. The court can also override an agents decision on the ground that such decision was made in bad faith or not in accordance with the statute. In february of 2010 the new york state senate passed the family health care decisions act fhcda that created a legal mechanism for the appointment of a health care surrogate to make health care. There may come a time when i am unable, due to incapacity, to make my own health care decisions.
One may choose not to complete this form and hisher current living. While you may complete either the health care proxy form or the health care proxy wallet card, nyrah recommends completing both and sharing the form with your medical providers. Health care proxy form massachusetts medical society. Massachusetts law about health care proxies and living. The partnership grants permission to reproduce this document in its entirety, so long as the source, including this statement, is shown. A health care representative is a person whom you authorize in writing to make any and all health care decisions on your behalf including the decision whether to withhold or withdraw life support systems.
A health care proxy may be a legally binding document. Suggested form of a health care surrogate, florida. The health care proxy is a simple legal document that allows you to name someone you know and trust to make health care decisions for you if, for any reason and at any time, you become unable to make or communicate those decisions. Health care organizations, clinicians, professionals, and others can purchase the form in quantity, or secure a license from massachusetts health decisions, the nonprofit publisher of the form and educational materials related to the massachusetts health care proxy. If one chooses to complete a georgia advance directive for health care, it will replace any other advance directive for health care, durable power of attorney for health care, health care proxy, or living will that currently is in place. Once this form is completed and properly executed, a copy should. The document can be useful to have in place in the event you are incapacitated in an accident or otherwise. Form for appointing an agent to make health care decisions for you if you lose the ability to make decisions yourself keywords. Advance directive is the general term that refers to the various documents that could include a living will, instruction directive, health care proxy or health care power of attorney.
The health care proxy statute provides the legal ability for the family and others to take over someones health decisions if the incapacitated person is unable to make health care decisions themselves. Health care proxy fillable pdf with instructions revised 112017. An advance health care directive is a written set of instructions expressing your wishes for medical treatment. The massachusetts health care proxy form massachusetts. Health care proxy information and forms february 17, 2015 the health care proxy is a simple document, legally valid in massachusetts, which allows you to name someone an agent to make health care decisions on your behalf if you are unable to make or communicate those decisions.
Nursing facility residents can obtain this form from your social work department. The florida designation of health care surrogate lets you name a competent adult to make decisions about your medical care, including decisions about lifeprolonging procedures, if you can no longer speak for yourself. Massachusetts health care proxy instructions and form. The attached forms are provided as is and are not the substitute for the advice of an attorney. A health care proxy is used in florida when someone is incapacitated and has not created a designation of health care surrogate or the designated surrogate is unable or unwilling to act. Massachusetts health care proxy form massachusetts. Before signing, you should understand the following facts. Free medical power of attorney virginia form adobe pdf. The directions in this form will be followed even if you do not name a health care proxy. Massachusetts health care proxy medical poa form, also referred to as a medical power of attorney, allows users to appoint an individual to represent their medical interests if they, for some reason, are unable to speak for themselves. Chinese, spanish, haitian creole, korean, russian if you are a provider and wish to order multiple copies, fill out the publication request order form and mail it to the address listed at the top of the form or email it to ogs. Massachusetts health care proxy form we, the undersigned witnesses, each declare in the presence of the principal that neither of us has been named as health care agent or alternate health care agent in this health care proxy, and we further declare that the principal signed this instrument as hisher health care proxy, or directed its execution. The person you appoint as your proxy cannot be an operator, administrator or employee of a treating health care facility, unless he or she is related to your by blood, marriage or adoption. Molst is very different from a health care proxy form, because 1 it is not for everyone, and 2 it is a medical order form like a prescription that must be filled out by a clinician in the context of discussions with the patient.
This health care proxy shall take effect, if and when i am unable to make my own health care decisions. The link above also contains a health care proxy form. My health care proxy is authorized to make whatever health care decisions i could make if i were able, except that decisions regarding lifesustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as i have indicated in the foregoing sections. Pennsylvania advance health care directive this form lets you have a say about how you want to be treated if you get very sick. A health care representative does not act unless you are unable to make or communicate your decisions about your medical care.
This form gives the person you choose as your agent the authority to make all health care. In some states, this document may be known as either a living will or an advance healthcare directive. Appointing your health care agent in new york state. To make things a little confusing, states use various terms to describe their advance directive forms. If you have no one you can appoint or dont want to appoint someone, you can also give specific instructions about treatment in advance. Living wills and the appointment of a person who can function as your health care proxy are important decisions we all should make related to how we wish to. Consult an attorney if you need legal advice of any nature. Massachusetts health care proxy form massachusetts medical.
I understand that, as a competent adult, i have the right to make decisions about my health care. I understand that this authorization permits access to information about any care provided prior to the date of the authorization as well as any care and treatment provided while the authorization is valid. This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide lifesustaining treatment, unless. To help you in this process, this tool kit contains a variety of selfhelp worksheets, suggestions, and resources. Download the harrington healthcare proxy en espanol.
For a person with a current serious advancing illness, in addition to signing a health care proxy, using a medical form called molst may be an option. This health care proxy document, provided free of charge, gives a clear explanation of the responsibilities of a health care agent, and simple directions on how fill out and sign the form. There are currently 9 tools in all, each clearly labeled and user. The virginia medical power of attorney form is a health care plan consisting of two parts. About the health care proxy form this is an important legal document. Durable power of attorney for health care and living will file type. There are also instructions on how to revoke or cancel the document at a later date, if you choose to do so. Massachusetts health care proxy instructions and document. A copy of the form and information about the health care proxy is available from your health care provider. The ephi is being disclosed to allow my proxy to take a more active role in my health care.
Florida medical power of attorney form, also referred to as the florida designation of health care surrogate or advance directive, allows a person to appoint a surrogate and an alternate surrogate to make health care judgments if the principal issuing party suffers a medical event where he or she is unable to communicate healthcare wishes to health care providers. Health care proxy appointing your health care agent in. Please ask your primary care physician to discuss these documents with you. In these circumstances, those caring for me will need direction and will turn. Health care proxies and living wills spanish pdf important points.
Suggested form of a health care surrogate, florida statutes section 765. If you have special instructions for your agent, write them here. Mychart adult proxy authorization release of information form. The second section is the living will section in which you may make your wishes known regarding lifeprolonging treatment so your health care surrogate or doctor will know what you want them to do. Follow the stepbystep instructions and sign and date the health care proxy in front of two witnesses, who sign and date the document after you. The purpose and use of molst is very different from the use of a health care proxy. Secondly, the durable power of attorney for health care will be used by the principal to appoint an agent to manage all. It may contain a health care power of attorney, where you name a person called a health care agent to decide treatment for you, and a living will, where you tell your health care agent and health care providers your choices. Health care proxy appointing your health care agent in new york state author. A compilation of laws, regulations, and web sources on health care proxies and living wills by the trial court law libraries. About the health care proxy form the new york state health care proxy form is an important legal document. Free new york health care proxy medical poa form word pdf. Massachusetts health care proxy information, instructions, and form what does the health care proxy law allow. In massachusetts, if a person has lost the ability to make medical decisions e.
This living will has been prepared to conform to the law in the state of new york, and is intended to be clear and convincing evidence of my wishes regarding the health care decisions i have indicated below. Health care proxy the judicial title insurance agency llc. Also, if you wish to limit your agent s authority in any way. To plan for future medical care, all adults ages 18 and older should name appoint their health care agent by filling out and signing a legal form called a health care proxy form. A medical decision maker is a person who can make health care decisions for you if you are too sick to make them yourself. The designation of health care surrogate is especially useful because it appoints someone to speak for you. A healthcare proxy form lets you name someone to make decisions about your medical care including. This health care proxy form was prepared by the central massachusetts partnership to improve care at the end of life. The court will issue a decree on special proceeding in re.