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Health Care Proxy

Click here to download the Health Care Proxy form.

What is a Health Care Proxy?

A health care proxy is a type of an “advance directive”. It is a legal document that names the person you have chosen to make medical decisions for you when you cannot. This person whom you have chosen to represent you is known as the “proxy” or could be also referred to as your health care “agent”. Your proxy may act on your behalf only if your doctor determines that you are unable to make or communicate your own health decisions. It is important that you communicate your personal values, beliefs, and wishes to your proxy to ensure your preferences are followed.

What is the difference between a Health Care Proxy and a Living Will?

A living will is different than a health care proxy. A living will is a document which contains specific instructions concerning an adult’s wishes about the type of health care choices and treatments that an adult does or does not want to receive. It does not designate an agent to make health care decisions. The living will provides evidence of your wishes', however, in the state of Massachusetts it does not carry the same legal authority as a health care proxy who can carry out your wishes for you. Lawrence General Hospital recommends patients sign a health care proxy as evidence of your advance directive.

Who should be my Proxy? 

The proxy that you choose needs to be at least 18 years of age. Your proxy should be a person whom you trust and is able and willing to respect your values and beliefs; often a proxy is a family member or a close friend. Your proxy will have the right to receive medical and confidential information about you that she/he will need to have in order to make informed decisions on your behalf. You may choose two proxies, one being the primary agent and a second individual as your alternate. The alternate proxy will serve as your agent if your primary is unable or unwilling to do so.

Is a proxy required for treatment at Lawrence General Hospital?

No. You do not have to choose a health care proxy in order to receive treatment. If you have not completed a Health Care Proxy Form, your family may be asked to make decisions for you based on what they believe you would want. In some cases, a court may be asked to appoint a guardian to make decisions on your behalf.

May I revoke or change my Health Care Proxy?

Yes. You always have the right to change your health care proxy at any time.  If you divorce or separate from your spouse, who is the agent, the health care proxy is revoked. Please inform your health care team if you choose to make changes.

How can I obtain a Health Care Proxy Form?

A health care proxy form is available by clicking here, also available to you from the Admitting, Integrated Care and Pastoral Care Departments. Our out-patient sites have access to offer one as well if requested.

What should I do with a completed form?

Once you have completed your health care proxy form, keep the original and give copies to your agent(s). Be sure your physician also has a copy to include in your medical record. If being admitted to the hospital, presenting a completed health care proxy form is also very important as it can be placed in your medical chart and used to communicate your wishes to your health care team.

Whom do I contact with questions?

Your health care providers at the hospital can answer your questions. If you need more information, social workers in the Integrated Care Department can help. Please call 978-683-4000 ext. 2550. Translators are always available for your assistance if necessary. Another good resource available to you is located here

Completing the form:

  • Write in your name and address as the principal. Then write in the name, address and phone numbers of your agent(s) you have chosen. Be sure to include a second agent (an alternate) in case your first agent is not available to serve. The agent can be anyone except an employee of the health care facility you are currently a patient of, unless the agent is related to you by blood, marriage or adoption. Signing this gives your agent(s) ability to speak on your behalf in case you aren't able to do so.
  • Please write in, if anything, your wishes of what you may not want your agent(s) to do.
  • Sign and date the health care proxy in front of two witnesses. These witnesses can be anyone except your agent and the alternate.
  • The agents then have the option of signing the Statement of Health Care Agent which acknowledges that they agree to be your health care proxy.

For further questions on Health Care Proxy, please contact 978-683-4000 ext. 2550. Click here to download the Health Care Proxy form.

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