Connecticut Medical Power of Attorney Form


A Connecticut medical power of attorney is a form that represents an individual’s future health care and medical wishes in writing. As provided by § 19a-577, the wishes stated within must be followed should they become incapacitated to the point when they can no longer communicate on their own. The appointed agent must be someone who can be trusted with making wellness-related decisions. The physician must adhere to the instructions from the agent when providing care to the principal.


Also known as an: Appointment of Health Care Representative Form

Laws: Title 19a, Chapter 386w (Life Support Removal System)

Signing requirements (§ 19a-575a): The principal must sign the form in the presence of two (2) witnesses, who must also sign.

What’s Included

The form contains the following input fields:

  • Principal name
  • Agent name
  • Agent address
  • Agent phone – optional
  • Any limitations on what the agent can do – optional
    • E.g., Turning off life support.
  • Alternate agent name(s) and address(es) – optional
  • Duration of the agreement (end date) – optional
  • Notarization – optional
  • Witness signature fields (required)