Download and sue this form in the State of Connecticut to grant someone else to make Health and Medical related decisions on your behalf.
Text Version of the Form
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POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
Notice : The powers granted by this document are broad and sweeping. They are defined
in Connecticut Statutory Short Form Power of Attorney Act, sections 1-42 to 1-56,
inclusive, of the general statutes, which expressly permits the use of any other different
form of power of attorney desired by the parties concerned.
That I: _____________________________ do hereby appoint: ____________________
___________________________________________ my, attorney(s)-in-fact TO ACT: *
*If more than one agent is designated and the principal wishes each agent alone to be able
to exercise the power conferred, insert in this blank the word ‘severally’. Failure to make
any insertion or the insertion of the word ‘jointly’ shall require the agents to act jointly.
FIRST, In my name, place and stead in any way which I myself could do, if I were
personally present, with respect to health care decisions as defined in the Connecticut
Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to
act through an agent:
SECOND, With full and unqualified authority to delegate any all of the foregoing
powers to any person or persons whom my attorney(s)-in-fact shall select.
THIRD, Hereby ratifying and confirming all that said attorney(s) or substitute(s) do
or cause to be done.
FOURTH, This Power of Attorney shall not be affected by my subsequent
disability or incompetence of the principal herein named.
FIFTH, I hereby agree that any third party receiving a copy or facsimile of this
executed instrument may act in reliance thereon and that revocation or termination of this
power of attorney shall be ineffective as to such third party unless and until actual notice
or knowledge thereof shall have been received by such third party, and I, for myself and
my heirs, assigns and legal representatives, hereby agree to indemnify and hold harmless
any such third party from and against any and all claims that may arise against such third
party by reason of reliance on such copy of this instrument.
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I hereby declare that, with respect to the powers conferred by this executed instrument,
any and all such powers which may have been conferred in a previously executed
instrument or instruments are hereby revoked.
I further instruct that, upon being informed that my attending physician has determined
that I am unable to understand and appreciate the nature and consequences of health care
decisions and unable to reach and communicate an informed decision regarding
treatment, my attorney-in-fact to execute an affidavit stating said determination has
In Witness Whereof, I have hereunto signed my name and affixed my seal this _____
day of ________________________, 200____.
Signed, sealed and delivered in presence of:
Signature of Principal
(Number and Street) (Number and Street)
(City, State and Zip Code) (City, State and Zip Code)
STATE OF CONNECTICUT )
: ss. _______________________
COUNTY OF ________________________ )
The foregoing POWER OF ATTORNEY was acknowledged before me this day _______
of _____________________, 200____, by ____________________________________.
Commissioner of the Superior Court
My Commission expires:____________