Order Health Care Proxy Forms

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The Health Care Proxy

This simple, self-instructive Health Care Proxy is the most widely used form in the state since first published by Massachusetts Health Decisions in 1991. The form is printed on heavy white stock, has detachable information and instruction pages, and lists the 16 organizations and state agencies on the Massachusetts Health Care Proxy Task Force convened by MHD. A distinctive “zebra stripe” on the margin helps for quick location in the medical record. Size: 8½ x 11; 4 sides.

Individual Information Packet — For an individual or couple. Includes 2 copies of the Health Care Proxy; 1 User’s Guide pamphlet; 1 “Making Choices” brochure. $6 (includes sales tax and First Class USPS postage) 
100 copies: Health Care Proxy – ENGLISH — $32.50 (includes sales tax and shipping)
100 copies: Health Care Proxy – SPANISH (same size & format) — $32.50 (includes sales tax and shipping)
100 copies: Health Care Proxy – PORTUGUESE (same size & format) — $32.50 (includes sales tax and shipping)

Brochure: Making Choices About Your Health Care

This basic brochure introduces advance directives and their importance to good health care planning. The various directives are described (Health Care Proxy, Health Care Power of Attorney, Living Will) and reference is made to the documents recognized in each of the New England states. Also includes a brief resource list and user’s check list. “Making Choices…” is a useful brochure for distribution by health care providers and other professionals such as lawyers and members of the clergy. Size: 3½ x 8½; letter-fold.

100 copies: “Making Choices About Your Health Care” brochure — $26.25 (includes sales tax and shipping)

Booklet: User’s Guide to the Health Care Proxy

This 16-page booklet is the most informative publication specific to the Massachusetts Health Care Proxy. In question and answer format, the “User’s Guide” addresses the most commonly asked questions: Whom shall I choose as my Agent? What instructions should I give? What if I have a Living Will? Can I change my mind? The guide includes two wallet cards, a resource list, and a task list for personal completion. It is an excellent information source not only for patients, residents, and their families, but also for health care providers, educators, and others who want to provide solid, practical information to clients and the general public. (Size: 5½ x 8½; 16 pages)

100 copies: “User’s Guide” pamphlet — $62.50 (includes sales tax and shipping)

Office Pack

100 copies each of the Health Care Proxy, User’s Guide and Making Choices — $97 (includes sales tax and shipping)

Larger Quantities

If you need to order larger quantities, you can view or download a current price list (PDF).

Purchase a License

If you want to purchase a license to have the Proxy (in English or another languages) on your server or website, you can view or download licensing information (PDF).

About the Health Care Proxy in Other Languages, including American Sign Language

Find out about the Health Care Proxy in other languages, including American Sign Language.

Get a free copy of the Health Care Proxy

Get a free single copy of the Health Care Proxy form for personal use only.