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Connecticut Appointment of Health Care Representative

Representative acts when the attending physician determines the specified inability to make informed health care decisions.

Jurisdiction
Connecticut
Purpose
Medical & health care
Source / form version
Undated two-page form; optional witness affidavit on page 2
Resource format
PDF
Signing
Sign with two witnesses; the selected representative cannot witness. The separate notarized witness affidavit is optional.
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Sources checked: 2026-11-13. General information, not individual legal advice.

A focused representative appointment

This two-page government form appoints a primary health care representative and an alternate. It authorizes treatment decisions, including life-support decisions, subject to legal limits. The representative must follow your known wishes and use your best interests when your wishes do not resolve the situation. It does not transfer financial authority.

Sources: [1] [4] [2] [3]

Record wishes separately when needed

A living will records treatment directions; a representative appointment chooses the person who applies your wishes to a real situation. The Attorney General provides both a separate living will and a combined advance-directive packet. Discuss your priorities with your representative and make sure any separate living will agrees with this appointment.

Sources: [1] [4] [2] [3]

Witnesses and the optional affidavit

The appointment’s first page provides two witness signatures. Page 2 is an optional sworn affidavit by those witnesses; it does not replace the two witnesses on the appointment. Connecticut has additional rules for people signing in certain mental-health or developmental-services facilities. Ask the facility to arrange the required witnesses before signing, then give your representative and care team copies.

Sources: [1] [2] [3]

Common questions

Must I complete the notarized affidavit?

The packet labels the witness affidavit optional. The appointment itself still needs the required witnesses.

Sources: [2] [1]

Related forms and guides

Sources and verification

  1. Connecticut Office of the Attorney General: source and instructions (opens in a new tab)
  2. Signing and legal requirements (opens in a new tab)
  3. Authority and statutory guidance (opens in a new tab)
  4. Connecticut Office of the Attorney General: complete document (opens in a new tab)

Downloaded HTTP 200; 2 pages. Text inspected. This is the current linked representative PDF, not the older website HTML labeled “health care agent.”

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.