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APPOINTMENT OF HEALTH CARE REPRESENTATIVE
. DESIGNATION OF HEALTH CARE AGENT. I appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
to be my health care agent and my attorney-in-fact for health care decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions, and I am unable to reach and communicate an informed decision regarding treatment, my health care agent and attorney-in-fact for health care decisions is authorized to:
(a) Convey to my physician my wishes concerning the withholding or removal of life support systems;
(b) Take whatever actions are necessary to ensure that my wishes are given effect;
(c) Consent, refuse or withdraw consent to any medical treatment as long as such action is consistent with my wishes as stated in this document or otherwise made known concerning the withholding or removal of life support systems
(d) Consent to any medical treatment designated solely for the purpose of maintaining physical comfort.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
any needed organs or parts only the following organs or parts: any purpose permitted by law.these limited purposes: I authorize my agent, to the extent permitted by law, to consent to an autopsy.I do not authorize my agent to consent to an autopsy.
No bond shall be required of my conservator in any jurisdiction.
. GENERAL PROVISIONS.
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
These requests, appointments, and designations are made after careful reflection, while I am of sound mind, Any party receiving a duly executed copy or facsimile of this document may rely upon it unless such party has received actual notice of my revocation of it.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
STATEMENT OF WITNESSES
This document was signed in our presence by , the author of this document, who appeared to be eighteen years of age or older, of sound mind, and able to understand the nature and consequences of health care decisions at the time this document was signed. The author appeared to be under no improper influence. We have signed this document in the author's presence and at the author's request and in the presence of each other.
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
(NOTE: THE PERSON(S) APPOINTED AS HEALTH CARE AGENT OR ALTERNATE AGENT SHALL NOT ACT AS WITNESSES. Also, if the author resides in a facility operated or licensed by the department of mental health and addiction services, at least one witness shall be an individual who is NOT affiliated with the facility and at least one witness shall be a physician or clinical psychologist with specialized training in treating mental illness. For persons who reside in a facility operated or licensed by the department of mental retardation, at least one witness shall be an individual who is NOT affiliated with the facility and at least one witness shall be a physician or clinical psychologist with specialized training in developmental disabilities.)
(OPTIONAL FORM)
WITNESSES' AFFIDAVITS
STATE OF CONNECTICUT
COUNTY OF _________________________
We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of this document by the author of this document; that the author subscribed, published and declared the same to be the author's instructions, appointments and designation in our presence, that we thereafter subscribed the document as witnesses in the author's presence, at the author's request, and in the presence of each other, that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this ______ day of ____________________, _____.
________________________________________
________________________________________
Subscribed and sworn to before me this ______ day of ____________________, _____.
________________________________________
Commission of the Superior Court Notary Public
My commission expires: _________________________
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It is very simple to grant or obtain the authority you may need with a free Connecticut Medical Power of Attorney template from Rocket Lawyer:
This solution will often be notably less time-consuming than meeting and hiring your average law firm. If necessary, you may start a Medical PoA on behalf of your spouse or another relative, and then have them sign it when ready. Please remember that for a Power of Attorney to be legally valid, the principal must be a mentally competent adult when they sign. In the event that the principal is already incapacitated and unable to make their own decisions, a court-appointed conservatorship might be necessary. When managing this scenario, it would be best to work with a lawyer .
Anyone who is over 18 years old should have a Medical Power of Attorney. While it's tough to think about, a time could come when you cannot make your own medical decisions. Here are some common occasions where power of attorney would be helpful:
Regardless of whether this Connecticut Medical Power of Attorney is being prepared as part of a long-term plan or created as a result of an urgent issue, notarization and witnesses can help to protect your agent if someone questions their authority.
At times, in researching the subjects of elder care and estate planning, you may hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used interchangeably. In reality, they are the same. That being said, you should keep in mind that it's possible to have power of attorney over matters that aren't health-related. In that case, "proxy" generally is not the preferred term.
Connecticut Medical PoA forms are typically simple, but you or your agent may still have questions. The answer may depend on whom you approach, but often some attorneys may not even agree to review documents that they didn't draft. A better approach might be through the Rocket Lawyer attorney network. With a Premium membership, you can request a document review from an experienced attorney or pose additional questions related to your Medical Power of Attorney. As always, we're here for you.
The fees associated with hiring a lawyer to make a Medical Power of Attorney could be between two hundred and five hundred dollars, based on your location. When using Rocket Lawyer, you are not just filling out a Power of Attorney template. If you ever need support from a lawyer, your membership provides up to a 40% discount when you hire an attorney from our Rocket Lawyer attorney network.
With a membership, you can make edits, save it as a Word or PDF file, or print it. When you are ready to finish up your Power of Attorney, it will need to be signed. Your agent(s) and care providers should get copies of your fully executed document.
The guidelines for PoA forms will be different in each state; however, in Connecticut, your document will require two witnesses. Finally, as a basic rule, witnesses must be 18 years old or older, and no witness should simultaneously be designated as your PoA agent.
See Connecticut Medical/Healthcare Power of Attorney law: Sec. 19a-575
