Massachusetts Advance Directive

Information you will need

• Health Care Agent Address
• Health Care Agent Phone
• Health Care Agent Name
• Alternate Health Care Agent Name
• Alternate Health Care Agent Address
• First Witness Name
• Second Witness Name
• First Witness Signing Date
• Second Witness Signing Date
• Health Care Agent Signing Date
• Alt. Health Care Agent Signing Date
• Alt. Health Care Agent Phone
• Principal Name
• Principal Address
• Agent Status
• Health Care Agent Name and Contact Info
• Passions
• Quality of Life
• Values and Beliefs
• Comforts
• Life Prolonging Treatment
• Peaceful Death
• Notice of Decisions
• Current Medical Condition

…and 7 more fields in the PDF.

Completed by the agent and the provider.

The form includes a witness section.