Advance Directives Combined Form - Ct Attorney General printable pdf download

Advance Directives Combined Form - Ct Attorney General

ADVANCE DIRECTIVES OF ________________________________________

To Any Physician Who Is Treating Me, this document contains the following:

1. My Appointment of A Health Care Representative

2. My Living Will or Health Care Instructions

3. My Document of Anatomical Gift

4. The Designation of My Conservator Of The Person For My Future Incapacity

As my physician, you may rely on these health care instructions and decisions made by my

health care representative or conservator of my person, if I am unable to make a decision for

myself.

I choose not to appoint a health care representative, please go to the next page. ____

(Initial here)

APPOINTMENT OF HEALTH CARE REPRESENTATIVE

I appoint _______________________________________________ to be my health care

representative. If my attending physician determines that I am unable to understand and

appreciate the nature and consequences of health care decisions and unable to reach and

communicate an informed decision regarding treatment, my health care representative is

authorized make any and all health care decisions for me, including the decision to accept

or refuse any treatment, service or procedure used to diagnose or treat my physical or

mental condition and the decision to provide, withhold or withdraw life support systems,

except as otherwise provided by law which excludes for example psychosurgery or shock

therapy.

I direct my health care representative to make decisions on my behalf in accordance with my

wishes, as stated in this document or as otherwise known to my health care representative. In

the event my wishes are not clear or a situation arises that I did not anticipate, my health care

representative may make a decision in my best interests, based upon what is known of my

wishes.

If ________________________________ is unwilling or unable to serve as my health care

representative, I appoint ____________________________________ to be my alternative

health care representative.

I further instruct that as required by law my attending physician disclose to my health care

representative protected health information regarding my ability to understand and appreciate

the nature and consequences of health care decisions and to reach and communicate an

informed decision regarding treatment at the representative’s request made at anytime after I

sign this form.

Advance Directives Combined Form - Ct Attorney General