Healthcare Power of Attorney - Connecticut

Connecticut Appointment of Health Care Representative

This document is commonly described as a health-care power of attorney. Connecticut's current statutory term is "appointment of health care representative." It does not grant authority over financial or property matters.

The appointment generally becomes operative only when it is furnished to the attending physician or advanced practice registered nurse and that clinician determines that the principal is unable to understand and appreciate the nature and consequences of health-care decisions and to reach and communicate an informed decision.

1. Principal

Full legal name: [________________________________]

Date of birth: [__/__/____]

Address: [________________________________]

Telephone / email: [________________________________]

2. Primary Health Care Representative

I appoint the following person as my health care representative:

Name: [________________________________]

Relationship, if any: [________________________________]

Address: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

3. Alternate Health Care Representatives

If the primary representative is unwilling, unable, or unavailable to serve, I appoint the following alternates in the order listed.

4. Authority and Decision Standard

When this appointment is operative, my representative may make health-care decisions that I could make, including accepting or refusing treatment and providing, withholding, or withdrawing life support systems, subject to limits imposed by law and the instructions below.

My representative shall act according to my known wishes. If my wishes are unclear or a situation was not anticipated, my representative may decide in my best interests based on what is known of my wishes, values, beliefs, and goals.

My representative may request the written incapacity determination described in Conn. Gen. Stat. § 19a-579.

5. Instructions and Limits

☐ My representative has the full authority described above, subject to current law.

☐ My representative's authority is limited as follows:

[____________________________________________________________]

[____________________________________________________________]

My wishes, values, religious considerations, and treatment goals include:

[____________________________________________________________]

[____________________________________________________________]

Existing living will or other health-care instructions:

☐ None known

☐ Attached

☐ Kept at: [________________________________]

6. Conservator Nomination

☐ I do not nominate a conservator in this document.

☐ If a conservator of my person is needed, I nominate my primary health care representative.

☐ I nominate this other person: [________________________________]

Alternate nominee: [________________________________]

Unless a court orders otherwise, Connecticut law generally gives a health care representative's health-care decision precedence over a conservator's decision and limits a conservator's ability to revoke existing health-care instructions.

7. Medical Record and Provider Transfer

I request that a provider receiving this appointment place a copy in my medical record. A duly executed copy or facsimile may be relied upon unless the recipient has actual notice of revocation.

If an attending physician or provider is unwilling to comply with my wishes or the applicable advance-directive statutes, Connecticut law requires prompt reasonable steps to transfer my care to a willing physician or provider.

Emergency contact for locating the original or a current copy: [________________________________]

8. Eligibility Review

Before signing, review Conn. Gen. Stat. § 19a-576 with Connecticut counsel if the proposed representative is connected with a hospital, residential care home, nursing facility, or government agency financially responsible for the principal's care. A physician or advanced practice registered nurse may not act as both the principal's representative and attending physician or attending advanced practice registered nurse.

The representative or an alternate representative may not witness this appointment.

9. Revocation and Spouse Appointment

Except for the spouse-revocation rule in Conn. Gen. Stat. § 19a-579b, an appointment of health care representative may be revoked only by a writing signed by the principal and two witnesses. A provider receiving the revocation must make it part of the medical record.

Divorce, legal separation, annulment, or dissolution revokes a spouse's appointment unless the principal specifies otherwise.

☐ I intend my spouse's appointment to be revoked upon any event listed above.

☐ I specify that my spouse's appointment is not revoked solely by an event listed above, subject to legal review.

10. Principal's Signature

I am at least eighteen years old. I make this appointment voluntarily, after careful reflection, while able to understand its nature and consequences.

Signature: ________________________________________

Printed name: [________________________________]

Date: [__/__/____]

11. Witness Attestation

Two adult witnesses must sign. The appointed representative and alternates may not serve as witnesses. If the principal resides in a facility operated or licensed by the Department of Mental Health and Addiction Services or Department of Developmental Services, Conn. Gen. Stat. § 19a-576(b) or (c) imposes specialized witness requirements.

We witnessed the principal sign or acknowledge this appointment. The principal appeared to be at least eighteen years old, of sound mind, able to understand the nature and consequences of health-care decisions, and under no improper influence. We sign in the principal's presence, at the principal's request, and in each other's presence.

12. Optional Witness Affidavit

Conn. Gen. Stat. § 19a-578 permits the witnesses, at the principal's request, to make an affidavit before an officer authorized to administer oaths. The affidavit is optional and does not replace the two witness signatures above. Conn. Gen. Stat. §§ 3-95b(i) and 51-85a(g) prohibit remote acknowledgment of an appointment's self-proving affidavit by Connecticut notaries and commissioners of the Superior Court.

State of Connecticut

County of [________________________________]

The witnesses, being duly sworn, state that they witnessed the principal execute this appointment; the principal declared it to be the principal's appointment; the witnesses signed in the principal's presence, at the principal's request, and in each other's presence; and the principal appeared to be at least eighteen years old, of sound mind, able to understand the appointment's nature and consequences, and under no improper influence.

Witness 1 signature: ________________________________________

Witness 2 signature: ________________________________________

Subscribed and sworn before me on [__/__/____].

Officer signature: ________________________________________

Title / commission: [________________________________]

Commission expiration, if applicable: [__/__/____]

Sources and References

• Connecticut General Statutes, Chapter 368w — appointment, execution, activation, revocation, transfer, and Probate Court provisions
• Connecticut General Statutes, § 3-95b(i) — prohibited remote notarizations
• Connecticut General Statutes, § 51-85a(g) — prohibited remote acknowledgments
• Connecticut Office of the Attorney General — appointment of health care representative and advance-directive forms