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Health Care Proxy

Planning for medical treatment

Adults in Massachusetts have the right to accept or refuse medical treatment, including life-sustaining treatment. This means that you have the right to request or consent to treatment, to refuse treatment before it has started and to have treatment stopped once it has begun.

Sometimes due to illness or injury, people are unable to talk to a doctor and decide about treatment themselves. You may wish to plan in advance to make sure that your wishes will be followed if you become unable to decide for yourself. If you don’t plan ahead, family members or other people close to you may not be able to make decisions for you that follow your wishes.

Appointing someone you can trust to decide about treatment if you become unable to decide for yourself is the best way to protect your treatment wishes and interests. You have the right to appoint someone by filling out a form called a Health Care Proxy.

Download Health Care Proxy

To complete your Health Care Proxy, download and complete the form in its entirety.  Keep the original for your files and make a copy for your Primary Care Provider. If you have been a patient at Emerson Hospital, you may also send a copy to the address below for inclusion in your Emerson Hospital medical record.  Send a copy of your completed Health Care Proxy to: Medical Records Department, Emerson Hospital, 133 ORNAC, Concord, MA 01742.