Fillable Power Of Attorney For Health Care Decisions Form printable pdf download

Power Of Attorney For Health Care Decisions Form

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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.

Power Of Attorney For Health Care Decisions Form

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