This document includes instructions regarding life support, and the appointment of another person to make decisions for the Principal if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life support systems may be withheld or withdrawn. Press [Ctrl+F1] for more information.
This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Agent. Press [Ctrl+F1] for information.
This optional section gives the Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal may specify any personal values, religious beliefs, or preferences, such as location of care, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section enables the Principal to establish specific limitations upon the decision-making authority of the Agent. Press [Ctrl+F1] for more information.
This required section permits the Principal to indicate whether or not anatomical gifts are authorized. Options are also presented for consent to an autopsy and authorization for disposition of remains.
This required section states the name and address of the person to be appointed as conservator, if one is required. Press [Ctrl+F1] for more information.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
In this required section, the Principal acknowledges that he/she is of sound mind, and this document is effective until the party receiving it has actual notice of any revocation. Press [Ctrl+F1] for more information.
This section requires that two individuals witness the Principal's signature. The witnesses must also sign in the presence of the Principal. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
Health Care POA
HCP_CT
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
Enter the name of the person that this document is being created for
(the "Principal") or edit the information as desired. In this
document, the Principal requests that life support systems be
withdrawn or withheld if the Principal is in a terminal condition
with no hope of recovery. Press [Ctrl+F1] for more information.
HCT01
! Introductory Section (1 of 13)
THESE ARE MY HEALTH CARE INSTRUCTIONS, MY APPOINTMENT OF A HEALTH CARE AGENT, MY APPOINTMENT OF AN ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS, THE DESIGNATION OF MY CONSERVATOR OF THE PERSON FOR MY FUTURE INCAPACITY AND MY DOCUMENT OF ANATOMICAL GIFT.
To any physician who is treating me: These are my health care instructions including those concerning the withholding or withdrawal of life support systems, together with the appointment of my health care agent and my attorney-in-fact for health care decisions or conservator of my person, if I am unable to make a decision for myself.
It is important that this section be read to understand the purpose of this document. The person making the document will be referred to as the "Principal", and the person appointed to make health care decisions will be referred to as the "Agent". No fields need to be completed in this section. Press [Ctrl+F1] for more information.
HCT02
! Life Support Section (2 of 13)
!. HEALTH CARE INSTRUCTIONS.
I, !, the author of this document, request that, if my condition is deemed terminal,
! [optional COMA provision] or if I am determined to be permanently unconscious,
I be allowed to die and not be kept alive through life support systems. By terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life support systems, will, in the opinion of my attending physician, result in death within a relatively short time.
[This next sentence is automatically included if the COMA provision is selected]
! By permanently unconscious I mean that I am in a permanent coma or persistent vegetative state which is an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment.
The life support systems which I want to have withheld or withdrawn include, but are not limited to
_____ (Principal's initials) artificial means of providing nutrition and hydration
I do want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
! [User to compose own statement of desires concerning life support systems]
! If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life support systems, it is my preference that this document be given effect at that point.
! If life support systems will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
This required section includes the Principal's name and states the circumstances (coma and/or terminal condition) under which life support systems may be withheld or withdrawn. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for
(the "Principal") or edit the information as desired. In this
document, the Principal requests that life support systems be
withdrawn or withheld if the Principal is in a terminal condition
with no hope of recovery. Press [Ctrl+F1] for more information.
Enter an X if life support systems should be withheld or withdrawn if the Principal becomes permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X to include a paragraph that allows the Principal to state other desires concerning life support systems. For example, whether artificial nutrition/hydration may be withdrawn or withheld. Press [Ctrl+F1] for more information.
Use this space to state any other desires concerning life support systems.
Enter an X to include a pregnancy paragraph that allows the Principal to state her preference regarding the effect of this document if she is pregnant. Press [Ctrl+F1] for more information.
Enter an X to request that life support systems be withheld or withdrawn if it is determined that the fetus could not develop to the point of live birth with the continued application of life support systems.
Enter an X to request that consideration be given to the impact of physical harm or pain to the Principal in determining whether life support systems should be withheld or withdrawn if the Principal is pregnant.
"HCT03
! Designation of Agent Section (3 of 13)
!. DESIGNATION OF HEALTH CARE AGENT. I appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
to be my health care agent and my attorney-in-fact for health care decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions, and I am unable to reach and communicate an informed decision regarding treatment, my health care agent and attorney-in-fact for health care decisions is authorized to:
(a) Convey to my physician my wishes concerning the withholding or removal of life support systems;
(b) Take whatever actions are necessary to ensure that my wishes are given effect;
(c) Consent, refuse or withdraw consent to any medical treatment as long as such action is consistent with my wishes concerning the withholding or removal of life support systems; and
(d) Consent to any medical treatment designated solely for the purpose of maintaining physical comfort.
! If ! is unwilling or unable to serve as my health care agent and my attorney-in-fact for health care decisions, I appoint:
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
! SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
to be my alternative health care agent and my attorney-in-fact for health care decisions.
NOTICE: The following persons should not be appointed as a health care agent or alternate health care agent:
(1) your attending physician;
(2) an operator, administrator, or employee of a hospital, home for the aged, rest home with nursing supervision, or chronic and convalescent nursing home, if the Principal at the time of the appointment, is a patient or a resident of, or has applied for admission to one of these facilities; or
(3) an administrator or employee of a government agency which is financially responsible for the Principal's medical care.
Restrictions (2) and (3) do not apply if such operator, administrator, or employee is related to the Principal by blood, marriage, or adoption.
This required section states the name and address of the person appointed as Health Care Agent. The Agent will make health care decisions for the Principal if the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the Agent's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear later in this section. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so. Press [Ctrl+F1] for more information.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired. When naming an Agent, consider the availability of the Agent to confer with health care providers and access the Principal's medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country, if outside the United States. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
Enter an X to include the name of an Alternate Agent. You do not have to name an Alternate Agent. Press [Ctrl+F1] for more information.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired. When naming an Alternate Agent, consider the availability of the Alternate Agent to confer with health care providers.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Agent to discuss medical records or information with health care providers.
Enter a phone number at which the Alternate Agent may be reached during non-business.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent. Press [Ctrl+F1] for more information.
IGN06
! Optional Special Provisions Section (4 of 13)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values and Preferences Section (5 of 13)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
HCT06
! Optional Limits on Agent's Authority Section (6 of 13)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limits on the Agent's authority to make decisions on behalf of the Principal.
HCT07
! Treatment of Body Section (7 of 13)
!. TREATMENT OF BODY.
! I desire that no anatomical gifts be made.
! I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. I give
! any needed organs or parts
! only the following organs or parts:
to be donated for
! any purpose permitted by law.
! these limited purposes:
! [Autopsy statement]
! I authorize my agent, to the extent permitted by law, to consent to an autopsy.
! I do not authorize my agent to consent to an autopsy.
! I authorize my agent to direct the disposition of my remains.
This required section states whether or not the Agent has the authority to make anatomical gifts. Optional provisions are presented for consent to an autopsy and authorization for disposition of remains. Press [Ctrl+F1] for more information.
Enter an X if the Principal desires that no anatomical gifts be made upon death. Press [Ctrl+F1] for more information.
Enter an X if the Principal desires that anatomical gifts be made upon death. Press [Ctrl+F1] for more information.
Enter an X if the Principal authorizes the donation of any needed organs or parts.
Enter an X if the Principal authorizes the donation of only certain organs or parts.
Enter the names of the organs or parts which may be donated upon the Principal's death.
Enter an X if the above anatomical gift(s) may be made for any purpose permitted by law.
Enter an X if the above anatomical gift(s) may only be made for limited purposes, such as transplant.
Enter the limited purposes for which the above anatomical gift(s) may be made.
Enter an X to indicate whether the Agent may consent to an autopsy.
Enter an X if the Principal authorizes the Agent to consent to an autopsy.
Enter an X if the Principal DOES NOT authorize the Agent to consent to an autopsy.
Enter an X if the Principal authorizes the Agent to decide upon the method of disposal for the Principal's remains after death.
HCT08
! Nomination of Conservator Section (8 of 13)
!. NOMINATION OF CONSERVATOR. If a conservator of my person should need to be appointed, I designate
! my Agent (or Alternate Agent)
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
be appointed my conservator.
! If the person designated is unwilling or unable to serve as my conservator, I designate
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
No bond shall be required of my conservator in any jurisdiction.
This required section nominates a particular person to serve as the Principal's Conservator if one is required by legal proceedings. The person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Conservator should be the same person as the appointed Agent or Alternate Agent. Press [Ctrl+F1] for more information.
Enter an X if the nominated Conservator will be someone other than the Agent or Alternate Agent. Press [Ctrl+F1] for more information.
Enter the Conservator's name or use the P.I. Manager to select and paste a record.
Enter the Conservator's street address or edit the information as desired.
Enter the Conservator's extended street address or edit the information as desired.
Enter the Conservator's city or edit the information as desired. The Conservator will need to be available to act for the Principal.
Enter the Conservator's state/province or edit the information as desired.
Enter the Conservator's zip/postal code or edit the information as desired.
Enter an X to include the Conservator's country, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Conservator for the Principal.
Enter the country or edit the information as desired.
Enter an X to include the name of an Alternate Conservator. You do not have to name an Alternate Conservator.
Enter the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Principal.
Enter the Guardian's state/province or edit the information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Principal.
IGN16
! Hold Harmless Section (9 of 13)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
This is a required section in which the Principal states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
IGN17
! Severability Section (10 of 13)
!. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
HCT11
! Signature Section (11 of 13)
[This document must be signed in the presence of two witnesses.]
These requests, appointments, and designations are made after careful reflection, while I am of sound mind. Any party receiving a duly executed copy or facsimile of this document may rely upon it unless such party has received actual notice of my revocation of it.
Signed on _____ day of _______________, 19___.
________________________________________
Signature
Principal Name: !
City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's county or parish or edit the information as desired. The other address information was transferred from a previous section and can be modified only by returning to that section.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the Principal's country or edit the information as desired.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file advance directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Principal's social security number or edit the information as desired.
HCT12
! Witness Signature Section (12 of 13)
STATEMENT OF WITNESSES
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 influence. We have signed this document in the author's presence and at the author's request and in the presence of each other.
(NOTE: THE PERSON(S) APPOINTED AS HEALTH CARE AGENT OR ALTERNATE AGENT SHALL NOT ACT AS WITNESSES. Also, if the author resides in a facility operated or licensed by the department of mental health, at least one witness shall be an individual who is NOT affiliated with the facility and at least one witness shall be a physician or clinical psychologist with specialized training in treating mental illness. For persons who reside in a facility operated or licensed by the department of mental retardation, at least one witness shall be an individual who is NOT affiliated with the facility and at least one witness shall be a physician or clinical psychologist with specialized training in developmental disabilities.)
STATE OF CONNECTICUT
COUNTY OF ____________________
We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, the appointments of a health care agent and an attorney-in-fact, the designation of a conservator for future incapacity and a document of anatomical gift 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 affidavit at the author's request this _____ day of _______________, 19____.
________________________________________
Witness
________________________________________
Witness
Subscribed and sworn to before me this _____ day of ___________________, 19____.
________________________________________
Commission of the Superior Court Notary Public
My commission expires: _________________________
This document requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
DOM01
! Health Care Document Information Section (13 of 13)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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