Connecticut Medical Power of Attorney Form

The Connecticut medical power of attorney form is a legal instrument that allows a Principal to select, in advance, the person that they would like to make healthcare decisions for them if and when they become unable to make medical decisions for themselves. The person the principal chooses will be their representative for purposes of healthcare decision making only. It’s important for the Principal to understand that they may have more than one person acting on their behalf either jointly or individually, also known as “severally.” It’s also important to be aware that this document may be revoked in writing, with two witnesses signatures. (See CT.  sections 1-42 to 1-56, inclusive, of the general statutes).

How To Write

Step 1 – Begin by downloading the form and reading the information at the top of the page.

Step 2 – Appointment of Attorney(s) in Fact/Agent(s) – In the first blank lines on the page enter the following:

  • Printed or typed name of the Principal
  • The second blank line will require the printed or typed name of the Principal’s selected Attorney in Fact/Agent
  • If the Principal wishes to appoint more than one Attorney in Fact/Agent, they may add a sheet with either jointly acting agents or individually acting agents. Simply place their information on a separate sheet and specify how you would like the agents to act on your behalf. You may also provide “Successor” Attorney(s) in Fact, in the event any of the first named agents become unwilling or unable to act on your behalf with regard to your health care decisions.

Step 3 – The Principal must read and accept all of the remaining paragraphs.

Step 4 – Notarization and Witnesses – You must then acquire the services of a notary public:

  • Once you are before the notary, they will complete the information with regard to their commission
  • The principal will then sign the document on their own behalf
  • The two required witnesses must provide the following respectively:
  • Witness’ Signature
  • Physical Address
  • City, State and Zip Code
  • The notary will then complete the required information and affix their state seal
  • The notary will hand the document back to the Principal
  • Copies must be made and provided to each person who has provided signature with the original being provided to the attorney in fact/agent