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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 – This is employed to provide a representative with the authority to conduct financial transactions and the like on your behalf.

How to Write

1 – This Appointment Form Should Be Accessed On This Page

Download the Connecticut form using the button beneath the image preview. Take a moment to review this form carefully before filling in the required information.

2 – Each Health Care Representative Must Be Documented Within The Required Statements

In the second paragraph, put in the name of your representative.

In the second to last paragraph, locate the first blank line then re-enter the Name of the Health Care Agent previously named. If the Principal has decided upon an Alternative Health Care Representative, then record the Name of the Alternative Health Care Agent on the second blank space.

3 – To Execute This Form The Principal Must Supply A Notarized Signature With Witness Testimony

Before you sign, make sure you have your witnesses and notary available to witness you signing and dating the document. Make sure they sign, too, attesting to your sound mind. The Principal, granting Authority, should enter the Date of Signature then sign his or her Name in the appropriate spaces below the statement “This Request Is Made, After Careful Reflection, While I Am Of Sound Mind.”

Enter the full Name of the Signature Principal on the first blank line after the heading “Witnesses’ Statement.” Then, each Witness to the Principal Signature must sign his or her Name and record his or her Address after reading the provided statement.

Next, the Witnesses and the attending Notary Public must combine their efforts to complete the “Witnesses’ Affidavits” section. Each participating Witness may only complete and sign this section under the direction of the Notary Public.


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