Connecticut Medical Power of Attorney
This Connecticut Medical Power of Attorney ("Document") is a legal form that allows the principal, or person creating the Document, to appoint an agent, also known as a health care representative, to make health care decisions on their behalf if they are unable to do so. This Document is made under the authority of the Connecticut Uniform Power of Attorney for Health Care Act.
Principal Information
Full Name: _____________________________
Date of Birth: _____________________________
Address: __________________________________
City: _________________________ State: CT Zip Code: ___________
Phone Number: _____________________________
Agent/Health Care Representative Information
Full Name: _____________________________
Relationship to Principal: _____________________________
Address: __________________________________
City: _________________________ State: _____ Zip Code: ___________
Phone Number: _____________________________
Alternate Phone Number: _____________________________
Alternate Agent/Health Care Representative Information (Optional)
Full Name: _____________________________
Relationship to Principal: _____________________________
Address: __________________________________
City: _________________________ State: _____ Zip Code: ___________
Phone Number: _____________________________
Alternate Phone Number: _____________________________
Powers Granted to Agent
This Document grants the appointed agent the power to make all health care decisions for the principal that the principal could make, including decisions about medical treatment, surgery, and choosing or refusing life-sustaining treatment, except as otherwise stated in this Document.
Special Instructions
The principal may include any specific limitations on the agent's powers or provide special instructions here:
________________________________________________________________
________________________________________________________________
Effective Date and Signatures
This Document becomes effective when the principal is unable to make their own health care decisions as certified by a physician. This determination must be in writing and included in the principal's medical record.
Principal's Signature
Signature: _____________________________ Date: ___________
Agent's Acknowledgment
I, _____________________________, accept this designation as health care agent under the Connecticut Medical Power of Attorney of _____________________________ (Principal's name). I understand my responsibilities and agree to act according to the principal's wishes to the best of my ability.
Signature: _____________________________ Date: ___________
Witnesses
State law requires that this Document be signed in the presence of two adult witnesses. Neither witness should be the agent, the principal's health care provider, or an employee of the health care provider. Neither witness should be related to the principal by blood, marriage, or adoption, and neither should be entitled to any portion of the principal's estate.
Witness 1
Signature: _____________________________ Date: ___________
Print Name: _____________________________
Witness 2
Signature: _____________________________ Date: ___________
Print Name: _____________________________
Conclusion
This Document is an important tool for ensuring that the principal's health care wishes are honored. All adults are encouraged to have a conversation with their loved ones about their health care preferences and to complete a Medical Power of Attorney.