Patient Welcome Book - Harrington Memorial Hospital

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MASSACHUSETTS HEALTH CARE PROXY FORM — page 1 of 2
I, ________________________________________________________________________(the principal),
residing at________________________________________, __________________ County, Massachusetts,
pursuant to Massachusetts General Laws Chapter 201D, appoint the following person to be my Health Care
Agent:
Name: ___________________________________ Phone #: ___________________________________
Address: ______________________________ City/State/Zip: ___________________________________
If my Health Care Agent named above is not available, I name as an alternate Health Care Agent:
Name: ___________________________________ Phone #: ___________________________________
Address: ______________________________ City/State/Zip: ___________________________________
I give my Health Care Agent authority to make all health care decisions on my behalf if I become incapable
eral Information
of making such decisions for myself, including but not limited to decisions concerning initiation, continuing,
withdrawing or refusing any life-prolonging care, treatment, service or procedure, EXCEPT (here list the
limitations, IF ANY, you wish to place on your Agent's authority):
Patient
, who is a member ____________________________________________________________________________________
of Harrington’s medical staff, has
s for your admission. Your physician’s office will advise you
time. Please ____________________________________________________________________________________
be sure to arrive at the Hospital on time.
Registration
rmation is usually ____________________________________________________________________________________
completed during your pre-admission
egistration. The form is mailed to maternity patients
ou are admitted ____________________________________________________________________________________
through to the emergency room, your
or the physician on call, will be notified of your admission
____________________________________________________________________________________
lth insurance My identification Health Care card Agent at the shall time of make admission. health care decisions
Insurance
for me in accordance with my Health Care Agent's
nies have restrictions assessment which of require my wishes, notification including and approval my religious and moral beliefs. If my wishes are unknown, my Health
are presently Care employed, Agent shall check make with the such Personnel decisions for me only in accordance with my Health Care Agent's assessment of
ce of employment. If necessary, bring any appropriate forms,
mpleted, to Patient my best Registration interests. when you enter the Hospital.
My Agent may obtain any and all medical information, including confidential medical information, as I
es or tips by employees from patients, or their friends, is
ot offer money would or gifts be to entitled Hospital to personnel. receive. Photocopies of this Health
Gratuities
Care Proxy shall have the same force and effect as the
original and may be given to other health care providers.
estions, comments and safety concerns. You may be contacted Surveys and
a survey, or My you Health can contact Care Agent's the CEO’s authority Office at to the act hospital, on my behalf shall exist only for the period during which my attending
ridge, MA, or physician call 508-765-9771. determines You may that also I lack e-mail capacity us at to make or Patient communicate Satisfaction health care decisions for myself
ospital.org.
I sign this Health Care Proxy on ________________, Concerns 20_____ in the presence of two witnesses.
int should be brought to the immediate attention of the
ager or department head, and, if the resolution is not
During Your
ital’s President & Signed: CEO. Should ___________________________________________________________
you or your family
Hospitalization
oncerns about the care you are receiving, and a manager
feel free to contact (If the Principal the on-duty cannot nurse supervisor. sign) The You principal may is unable to sign and at the direction of the principal I have signed
r during your his/her hospitalization name by in dialing his/her zero presence for the and in the presence of two witnesses.
e hospital operator to have a nurse supervisor call your
e important to us in Name: our effort ______________________________________________________________________
to constantly provide
Street: _____________________________ City/Town: ______________________________
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