Connecticut Medical Power of Attorney Form [PDF]

Discover the benefits of creating a Connecticut medical power of attorney by using our professional and customizable medical POA template.

Last update: 27 Mar 2024

Connecticut Medical Power of Attorney Form [PDF]

The Connecticut medical power of attorney, or healthcare power of attorney, is a legal document that enables one person, called the principal, to authorize another person, called the agent or the attorney-in-fact, to represent them and make healthcare decisions on their behalf.

The principal usually issues the medical power of attorney if there is a high possibility that they will not be able to make decisions themselves in the near future. 

This can happen due to their unstable physical or mental health, or if they are about to undergo serious surgery. The principal can instruct the agent on what treatment they are willing or not willing to undergo.

Laws and Legal Requirements for a Medical Power of Attorney in Connecticut

Laws and Legal Requirements

Sections 19a-570 to 580 of the Connecticut General Statutes regulate matters connected to the Connecticut medical power of attorney.

Section 19a-576 provides that the medical power of attorney must be in writing. Additionally, a notary public and at least two witnesses must acknowledge the document

The witnesses must be at least 18 years old, and only one of your witnesses can be your healthcare representative, physician, or employee of the health facility in which you’re a patient.

As provided by Section 19a-579, the document will remain effective until you revoke it. You can also set the medical power of attorney expiration date when issuing it. 

How to Write a Medical Power of Attorney in Connecticut

Here, you can see the step-by-step process of drafting the Connecticut medical power of attorney using our medical power of attorney template.

How to Write a Medical Power of Attorney

#1. Access the Medical Power of Attorney Form

Here, you will find the medical power of attorney form that you can fill out by following the instructions of our professional legal document builder. 

First, you should fill out the basic information, such as the principal’s full name, mailing address, contact details, and date of issuing the medical power of attorney.

#2. Appoint a Healthcare Representative

This is your attorney-in-fact or an agent. It should be an adult with the legal capacity to represent you. You should choose a reliable and trustworthy person, considering the important matters they will have authority over.

In this section, you should enter the full name, mailing address, and contact details of your agent. Here, you should also include the medical power of attorney rights and limitations that will define your agent’s scope of authority.

#3. Identify an Alternative Healthcare Representative

This person is also referred to as the secondary agent or attorney-in-fact. They will act only in cases where the primary agent loses legal capacity or is, in some way, unable to represent the principal.

The secondary agent should also be an adult and have the legal capacity to represent the principal. You can name one, two, or more people as your secondary agents.

#4. Identify the Witnesses and Have Them Sign the Form

After finalizing the medical power of attorney template, you can print it and prepare it for the document's signature. As state law requires, you must sign the document before at least two witnesses.

Each witness must be at least 18 years old, and only one witness can be your healthcare representative, physician, or employee of the health facility in which you’re a patient.

#5. Notarize the Form

Finally, the notary public must acknowledge the Connecticut medical power of attorney. They will notarize the document and confirm that you and two witnesses have signed it before them. This will provide additional authenticity for the document and prevent potential fraud.

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