CONNECTICUT APPOINTMENT OF HEALTH CARE AGENT
Instant Download - Only $9.99
- Professional MS Word & PDF formatting
- Fully editable & reusable
- Lifetime updates
- Accuracy guarantee
Connecticut Appointment of Health Care Agent
I appoint ________________________ (Name) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and communicate an informed decision regarding treatment, my health care agent is authorized to:
(1) Convey to my physician my wishes concerning the withholding or removal of life support systems.
(2) Take whatever actions are necessary to ensure that my wishes are given effect.
If this person is unwilling or unable to serve as my health care agent, I appoint ______________________________ (Name) to be my alternative health care agent.
This request is made, after careful reflection, while I am of sound mind.
_______________________ (Printed Name)
This document was signed in our presence, by the above-named ______________________ (Name) who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed.
Other Forms You May Need
- Connecticut General Durable Power of Attorney for Property & Finances (Immediate)
- Connecticut General Durable Power of Attorney for Property & Finances (Upon Disability)
- Connecticut Form on Withdrawal of Life Support Systems
- HIPAA Authorization and Waiver
"Are these forms valid in my state?" At ILRG, we are committed to delivering top quality legal forms that are valid in all states. We will pay $50 to anyone who brings to our attention any form on our site that is not compliant with U.S. state law. See the terms and conditions for this offer for further information. ILRG guarantees your complete satisfaction with your purchase. If you are not 100 percent satisfied after purchasing from us, contact us for a full refund.