Health care proxy

A health care proxy lets you manage your family member's medical care.

It is usually meant for a medical emergency where the doctor thinks the person is unable to take part in treatment decisions.

If you want to make decisions for routine, non-emergency care, many doctors still use this form. But if you and your family member give conflicting instructions, the doctor must follow your family member's wishes.

Here's what you can do:

  1. Talk about this with your family member, a lawyer, and other helpful people like school staff, service providers, or doctors.

  2. Download and fill out the health proxy form by clicking the link at the end of this page.

    • In Section 1, fill in the information for your family member (the Principal). Then, fill in your own (you are the Health Care Agent). If you think you might not be available at all times in the future, you may also add an Alternate Agent.

    • In Section 2, you can list limits to the Agent's decision-making. If your family agrees that you need full authority, leave this section blank.

  3. BEFORE you sign the form, make sure you have 2 witnesses present. Witnesses must not be related to you and your family member by blood or marriage.

  4. Everyone signs the form:

    • your family member

    • the 2 witnesses

    • you (the Agent)

    • the Alternate Agent (if there is one)

  5. Make 5 photocopies of the form for:

    • your family member

    • yourself

    • the Alternate Agent (if there is one)

    • your family member's doctor

    • your family member's health insurance plan

You might also want to give copies to other family members or others who will be involved in healthcare decisions.

Sources: Jackins (2010), Nadworny & Haddad (2007), MA Medical Society