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Connecticut Medical Power of Attorney Form | Appointment of Health Care Representative

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Connecticut Medical Power of Attorney Form (Appointment of Health Care Representative) will deliver the ability to make health care decisions to an agent should the issuer become unable to do so due to trauma, unconsciousness, or some other condition that prevents the communication of health care wishes. This document is legal under state laws and it gives the representative the ability to make health care decisions for the individual based upon his or her living will if there is one, or their wishes as told to the representative. It is important that you inform the representative you appoint of your healthcare wishes.

Laws – C.G.S.A. § 19a-577


Durable (Financial) Power of Attorney – For monetary ($) reasons. Allows someone to appoint an individual to take care of their financial needs (e.g. paying taxes and bills, making deposits, etc.)

How to Write

Download: Adobe PDF

1 – Save The Paperwork To Set Health Care Instructions To Your Machine

The button under the image (“PDF”) and the link just above this area will grant access to this template. Open this file with your PDF editor or an up-to-date browser then save it to an accessible folder to your machine. Please note, some parts of this document may be filled out by a Preparer however, the Principal will need to supply several items to prove his or her intention. Once this paperwork has been saved to your machine, you may use it at your discretion.

2 – Supply The Title Page With The Requested Information

Locate the page titled “State Of Connecticut Consolidated Health Care Instructions And Advance Directives Of…” The blank spaces labeled “Printed Name” and “Address” below this title require the full name of the Principal. This is the individual whose treatment preferences are to be communicated to medical providers at a time when he or she is unable to communicate through this document’s execution. The identity and address of the Principal must be re-entered in the box at the top of the next page. Two blank spaces, “Printed Name” and “Address,” have been presented in this area to receive this information.

3 – Indicate If A Health Care Representative Is Being Elected

In “I. Appointment Of A Health Care Representative,” a Health Care Representative who the Principal is comfortable with may be appointed to make medical decisions for him or her. If the Principal does not wish to name such an Agent and would prefer to rely on this paperwork alone to deliver instructions to attending physicians, then he or she must initial the blank space in item A. If the Principal does wish to elect a Health Care Representative, then leave item A blank. If the Principal does wish to elect a Health Care Representative, then leave item A blank. To appoint a Health Care Agent for the Principal, enter the Health Care Agent’s full name on the first blank line in item B then, his or her complete address on the second blank space of this statement. In some cases, the Principal may wish the added security of naming a back-up Agent to assume the role of Health Care Representative if the individual named above cannot or will not represent the Principal’s wishes. If the Principal wishes to name an Alternative Health Care Representative, then locate item C. We will need to supplement the language in this item by placing the Principal’s full name on the first blank line, the full name of the Alternate Health Care Representative on the second blank line, and the complete address of the Health Care Representative on the last blank line. If there is no such entity, you may leave this item blank however, it is generally recommended to name an Alternative Health Care Representative if possible.

4 – The Principal’s Health Care Instructions May Be Presented

This paperwork gives the Principal the choice of either relying solely on his or her Health Care Representative to safeguard his or her interests or allow the Principal to document his or her treatment preferences directly to its contents. If the Principal does not wish to include Health Care Instructions then he or she should locate the blank line for item A in “II. Living Will And Health Care Instructions,” then, initial it. If the Principal does intend to deliver instructions here then item A should be left blank.

If the Principal intends to document his or her directives here, then make sure his or her name is supplied to the blank space before the words “..The Author Of This Document.” 

The next item, “C. Specific Instructions,” will require a record of the Principal’s decisions regarding a scenario where he or she requires a life support system to keep him or her alive. If the Principal does not wish to be kept alive by any kind of life support machine, then he or she must initial the first statement in this area “I Do Not Want Any Life Support Systems…” If the Principal will allow certain life support machines or systems employed to prolong his or her life but not others, then he or she should initial the blank space attached to the statement “I Do Not Want Any Life Support Systems Except The Following.” This choice will require some additional definition on the area directly below this statement. Now, if the Principal has indicated that some life support machines may be used then, we will need to indicate which life support systems he or she will allow attending physicians to use when prolonging his or her life. A list of such systems (“Cardiopulmonary Resuscitation,” “Artificial Respiration…,” and “Artificial Means Of Providing Nutrition And Hydration”) has been presented in a column on the left. Each item on this list will have a corresponding blank space in the column titled “Provide.” The Principal must locate the blank space for each life support system he or she will allow physicians to employ and initial it to approve its use. The last item, “Other,” has been included so the Principal can report any life support machines he or she approves of not on this list. Thus, for example, if the Principal will allow physicians to provide artificial nutrition/hydration using feeding tools but no other system on this list may be used then, he or she must initial the third blank line in the right column. The second item in this section will contain several empty lines. This area will accept any and all specific instructions the Principal has regarding scenarios where he or she is unable to communicate and is suffering an end-of-life event that will require medical intervention to manage pain or prolong life. The Principal take some time to discuss his or her concerns with a qualified physician then report the treatments he or she approves of and treatments he or she would not want to be used. If there is not enough room to supply this area with a complete report on the Principal’s preferences, then you may continue on a separate sheet of paper that is properly labeled and cited here.

5 – The Subject Of Anatomical Gifts Should Be Addressed

In the third section “III. Document Of Anatomical Gift,” the Principal may report his or her preferences regarding organ donations. If the Principal does not wish to make any anatomical gifts, then he or she should initial the blank space attached to statement A.  If the Principal does wish to make anatomical gifts, then he or she should initial statement “B.” In addition to initialing this statement, he or she will need to go through the items below it then mark the checkbox that applies to his or her preferences. The Principal should mark the first checkbox if he or she will donate “Any needed Organs Or Parts.”  If the Principal only intends to make certain anatomical gifts then, mark the second checkbox. You will also need to specify exactly which organs or body parts may be donated using the blank lines provided. For example, if the Principal wishes to donate only his or her liver. Then mark the second choice and write in “Only Approves Of Donating Liver.” Now the Principal may specify the purpose of his or her anatomical gifts. If the Principal will only allow an anatomical gift made for any legal purpose, then mark the first checkbox under “2. To Be Donated For.” If he or she only wishes an anatomical gift made for a specific reason, then mark the second checkbox and list the reasons on the blank lines after the words “(b) These Limited Purposes.” 

6 – Conservator May Be Nominated Through This Paperwork

Sometimes when an individual suffers a traumatic medical event with long-term consequences the courts will decide that Conservator must safeguard the Principal’s interests. This type of power is different from the ones given here for a few reasons. The most notable one is that it is the courts and not the Principal who will decide upon the identity of the Conservator. The Principal does have the option to nominate an individual for the court’s consideration through this paperwork, if a court-appointed Conservator must be appointed. If the Principal chooses to waive this option, then he or she should initial item A in “IV. Designation Of A Conservator Of The Person For My Future Incapacity.” If the Principal would like to nominate a Conservator, then fill in the full name of the Principal’s nomination on the first blank line in item B. In addition, the complete address of this nominee should be supplied on the second blank space. Item C will give us an opportunity to nominate a back-up Conservator who can step into this role should the person listed above cannot act in this capacity. If the Principal has an individual in mind, then record the full name of the back-up Conservator on the first blank line in item C along with his or her complete address on the second blank space.

7 – The Principal’s Signature And A Signature Witness Affidavit Are Required

The last section of this document “V Capacity To Execute Document – Signature” will enable the Principal to formally declare the authenticity of this document. He or she should sign the blank space labeled Signature then print his or her name on the blank line below this. Once the Principal’s signature and printed name have been presented, he or she must enter the current calendar date on the blank lines labeled “Dated.” This will act as the Principal’s signature date. This directive will require that two Witnesses observe the Principal’s signing. These parties will take control of this paperwork after the Principal has signed this document. To begin, make sure the Principal’s full name is reported on the blank line in the “Witnesses’ Statements” paragraph. Each Witness must tend to a unique column below this paragraph. He or she must sign the “Witness’ Signature” line then print his or her name on the “Witness’ Name Printed” line. The two blank lines below this require the building number, street name, city, state, and zip code of the Witness’ address. The final page, “Witnesses’ Affidavits” is an optional item. Some may prefer to include a notarized affidavit to add more credibility to the document above. If this is the case, a Notary Public will be necessary to provide all items on this page except for the Witnesses’ signatures, printed names, and addresses necessary for the notarization of this paperwork.

 


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