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Connecticut Health Care Power of Attorney Form

The Connecticut health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Connecticut Health Care Power of Attorney Form
Connecticut Health Care Power of Attorney Form
POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
Notice: The powers granted by this document are broad and sweeping. They are defined
in Connecticut Statutory Short Form Power of Attorney Act, sections 1-42 to 1-56,
inclusive, of the general statutes, which expressly permits the use of any other different
form of power of attorney desired by the parties concerned.
KNOW ALL MEN BY THESE PRESENTS, Which are intended to constitute a
GENERAL POWER OF ATTORNEY pursuant to Connecticut Statutory Short Form
Power of Attorney Act:
That I: _____________________________ do hereby appoint: ____________________
___________________________________________ my, attorney(s)-in-fact TO ACT: *
*If more than one agent is designated and the principal wishes each agent alone to be able
to exercise the power conferred, insert in this blank the word 'severally'. Failure to make
any insertion or the insertion of the word 'jointly' shall require the agents to act jointly.
FIRST, In my name, place and stead in any way which I myself could do, if I were
personally present, with respect to
health care decisions as defined in the Connecticut
Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to
act through an agent:
SECOND, With full and unqualified authority to delegate any all of the foregoing
powers to any person or persons whom my attorney(s)-in-fact shall select.
THIRD, Hereby ratifying and confirming all that said attorney(s) or substitute(s) do
or cause to be done.
FOURTH, This Power of Attorney shall not be affected by my subsequent
disability or incompetence of the principal herein named.
FIFTH, I hereby agree that any third party receiving a copy or facsimile of this
executed instrument may act in reliance thereon and that revocation or termination of this
power of attorney shall be ineffective as to such third party unless and until actual notice
or knowledge thereof shall have been received by such third party, and I, for myself and
my heirs, assigns and legal representatives, hereby agree to indemnify and hold harmless
any such third party from and against any and all claims that may arise against such third
party by reason of reliance on such copy of this instrument.
Connecticut Health Care Power of Attorney Form
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