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Free Connecticut Medical Power of Attorney Form

A Connecticut medical power of attorney is called an appointment of health care representative under state law. Complete it with our step-by-step questionnaire and sign it with two adult witnesses.

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What Is a Medical Power of Attorney in Connecticut?

You create a Connecticut medical power of attorney by signing an appointment of health care representative. Your representative can make any and all health care decisions for you once your doctor finds you incapacitated, including decisions about life support.

Connecticut Rules for Appointing a Representative

The rules sit in Chapter 368w of the Connecticut General Statutes, mainly § 19a-576.

You Need Two Adult Witnesses

Anyone 18 or older can appoint a representative. You sign and date the document in front of two adult witnesses, who also sign it. The person you appoint cannot act as a witness or sign the document.

Special Witnesses for Some Residents

Extra rules apply if you live in a facility run or licensed by certain state departments:

  • Department of Mental Health and Addiction Services facilities need one witness unaffiliated with the facility, plus one physician, APRN, or licensed clinical psychologist trained in treating mental illness
  • Department of Developmental Services facilities need one unaffiliated witness, plus one physician, APRN, or licensed clinical psychologist trained in developmental disabilities

Who Cannot Be Your Representative

If you are a patient or resident of a hospital, residential care home, rest home with nursing supervision, or chronic and convalescent nursing home, its operators, administrators, and employees cannot be your representative. Administrators and employees of a government agency financially responsible for your care are barred too. A relative by blood, marriage, or adoption is the exception. Your attending physician or APRN also cannot serve as both your doctor and your representative.

Does a Connecticut Medical Power of Attorney Need a Notary?

No, Connecticut requires two adult witnesses, not a notary. Section 19a-576 lists only the witness signatures.

There is one optional step that involves an official, though. At your request, your witnesses can sign a sworn affidavit before someone authorized to administer oaths. A Connecticut court then accepts that affidavit as if the witnesses had testified in person. The combined statutory form in § 19a-575a includes a space for this affidavit.

Revoking Takes Two Witnesses Too

You can only revoke a Connecticut health care representative appointment in writing, signed by you and two witnesses. Divorce, legal separation, or annulment is the exception: it automatically revokes a spouse’s appointment unless you specify otherwise. Revoking the appointment does not cancel your living will.

How to Sign Your Connecticut Medical Power of Attorney

Take these steps to complete your Connecticut medical power of attorney form:

  1. Name your health care representative and an alternate.
  2. Add any living will instructions you want in the same document.
  3. Line up two adult witnesses who are not your representative.
  4. Sign and date the form while both witnesses watch, and have them sign.
  5. Ask your witnesses to complete the optional sworn affidavit, if you want it.
  6. Give a copy to your doctor, who must add it to your medical record.

What to Include in Your Connecticut Form

Connecticut offers two optional forms in statute: a stand-alone appointment in § 19a-577 and a combined form in § 19a-575a. The combined version can also cover:

  • Your living will instructions, including choices if you are pregnant
  • Designation of a conservator of the person for future incapacity
  • An anatomical gift

Your Connecticut medical power of attorney becomes operative once your attending physician or APRN has the document and determines you are incapacitated. Your representative can ask for that determination in writing.