What type of health care would you want if you became too sick to let your providers know? With advance care planning, you can stay in control and make sure your wishes are known and valued.

UMass Memorial Health - Health Care Proxy  

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.

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Please print and complete all fields in the proxy by hand. The proxy to be signed by patient and two witnesses, neither of whom can be the health care agent or alternate agent. The Health Care Proxy form does not require notarization or a lawyer. Once completed, bring the form to your providers office so it can be placed in your medical record or you can upload the document to your myChart portal.