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Appointment of Health Care Representative

If you wish to appoint a health care representative to make decisions related to your health on your behalf, you have to complete and submit the following form.

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APPOINTMENT OF HEALTH CARE  R EPRESENTATIVE 
I understand that, as a competent adult, I have the right to make decisions about my health 
care. There may come a time when I am unable, due to incapacity, to make my own health 
care decisions. In these circumstances, those caring for me will need direction and will turn 
to someone who knows my values and health care wishes. By signing this appointment of 
health care representative, I appoint a health care representative with legal authority to 
make health care decisions on my behalf in such case or at such time.  
I appoint ________________________________ ___ to be my health care representative.   
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  my health care representative is authorized to  (1)  accept 
or refuse any treatment, service or procedure used to diagnose or treat my physical 
or mental condition,  except as otherwi se provided by law, such as psychosurgery or 
shock therapy as defined in Conn. Gen. Stat. ยง  17a- 540, and  (2) make the decision to 
provide, withhold or withdraw life support systems .  
I direct my health care representative to make decisions on my behalf in  accordance with 
my wishes as stated in a living will, or as otherwise known to my health care representative. 
In the event my wishes are not clear or a situation arises that I did not anticipate, my health 
care representative may make a decision in my bes t interests, based upon what is known 
of my wishes.   
If _______________ _________________ is unwilling or unable to serve as my health care 
representative, I appoint ____________________________________ to be my alternative 
health care representative.  
This  request is made, after careful reflection, while I am of sound mind.   
 
______ / ______ / ______   (Date)             X______________________________ 
            
WITNESSES' STATEMENTS 
 
This document was signed in our presence by _____________________________ the author of 
this document, 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 this document was 
signed. The author appeared to be under no improper infl uence. We have subscribed this 
document in the author's presence and at the author's request and in the presence of each 
other.  
 
x__________________________                           x___________________________   
(Witness)                                                                           (Witness)                 
x__________________________                           x___________________________   
(Number and Street)                                                     (Number and Street)  
x__________________________                           x___________________________   
(City, State and Zip Code)                                          (City, State and Zip Code)

OPTIONAL FORM 	
 
 
 
WITNESSES' AFFIDAVITS  
 
STATE OF CONNECTICUT                                                 )   
                                                                                                        )                     
                                                                                     )        : ss.__________________________  
              )                              (Town)  
COUNTY OF _ ___________________________         )                                         
 
We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of th is 
appointment of a health care representative  by the author of this document; that the author 
subscribed, published and declared the same to be the author's instructions, appointments and 
designation in our presence; that we thereafter subscribed the document as witnesses in the 
author's presence, at the author's request and in the presence of each other; that at the time of 
the execution of said document the author appeared to us to be eighteen years of age or older, 
of sound mind, able to understand the nature and consequences of said document, and under 
no improper influence, and we make this affi davit at the author's request this _____ day of 
_____________________, 20____.  
 
 
 
x_____________________________                               x______ _________________________   
(Witness)                                                                                              (Witness)  
x_____________________________                                x_______________________________   
(Number and Street)                                                                        (Number and Street)  	
x_____________________________                                 x_ ___ ___________________________   
(City, State and Zip Code)                                                             (City, State and Zip Code)   
 
 
Subscribed and sworn to before me by ________ ___________and ____________ __________, 
the signing witness es to the foregoing affidavit  this ______ day of _________________, 
20____.  
                                                                                                                                                                                           
                                                                                                                            	
                                                                                      
___ ______________________________  
                                                                                    
Commissioner of the Superior Court            
  Notary Public                                                        
My Commission expires:   _____________  	
 
 
 
 
(Print or type name of all persons signing under all signatures)
Next: Advance Health Care Directive Previous: Advance Health Care Directive of __________________.
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