Valid Medical Power of Attorney Template for the State of Connecticut

Connecticut Medical Power of Attorney

This Connecticut Medical Power of Attorney is a legal document that allows an individual (referred to as the Principal) to designate another person (referred to as the Agent), to make healthcare decisions on the Principal's behalf should they become unable to do so. This document is in accordance with the Connecticut General Statutes, specifically addressing the delegation of authority regarding healthcare decisions.

Principal Information

Name: ________________________________________________________

Address: _____________________________________________________

City, State, ZIP: _____________________________________________

Phone Number: _______________________________________________

Date of Birth: _____________________ Social Security Number: ___________

Agent Information

Name: ________________________________________________________

Address: _____________________________________________________

City, State, ZIP: _____________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

In the event my above-named Agent is unable or unwilling to act, I designate the following individual as my successor Agent:

Name: ________________________________________________________

Address: _____________________________________________________

City, State, ZIP: _____________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Powers Granted

I hereby grant my Agent full power and authority to make healthcare decisions on my behalf, including but not limited to, the power to:

1. Consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, or diagnostic procedures.
2. Access my medical records and discuss my condition with healthcare providers.
3. Decide on my behalf regarding organ and tissue donation, in accordance with Connecticut law.
4. Make decisions about my final arrangements, including burial or cremation, in accordance with my wishes, to the extent known.

Special Instructions

In the space below, you may give special instructions limiting or extending the powers granted to your Agent.

________________________________________________________________

________________________________________________________________

________________________________________________________________

Duration

This Medical Power of Attorney becomes effective immediately upon signing and continues in effect until revoked by me, the Principal, in writing, or as otherwise provided by Connecticut law.

Signature

Principal's Signature: ___________________________ Date: ________________

Agent's Signature: _______________________________ Date: ________________

Witness Signature: ______________________________ Date: ________________

Print Name of Witness: _____________________________________________

This document was signed in my presence and the Principal, to the best of my knowledge, appears to be of sound mind and under no duress, fraud, or undue influence.

Notarization

This section should be completed by a Notary Public.

State of Connecticut

County of ________________________

On this ____ day of ____________, 20___, before me, the undersigned Notary Public, personally appeared ________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

Notary Public Signature: _____________________ My commission expires: ___________

Seal: