Fillable Living Will Form (Page 4 of 10) in pdf

Who can I name as my health care agent or as my attorney-in-fact for health care or as my

conservator? You can name the same person to be your health care agent and as your attorney-in-fact for

health care decisions or to be your conservator. The following persons cannot be named your health care

agent:

•

your physician;

•

if you are a patient at a hospital or nursing home or if you have applied for admission, the operators,

administrators, and employees of the facility;

•

an administrator or employee of a government agency responsible for paying for your medical care.

Other than these restrictions, you can name anyone you feel is appropriate to serve as your health care agent.

Although these restrictions only apply to the health care agent, it may be a good idea to follow them in

deciding who should hold your durable power of attorney or be named as conservator. Of course, you should

speak to the person whom you intend to name and be sure of his or her willingness to serve.

Do I need a lawyer to create an advance directive? No. You do not need a lawyer to create an advance

directive. You can use the forms in this booklet. Please note that if you appoint an attorney-in-fact for health

care decisions, a notary public or a lawyer must notarize your signature. The optional form called a

witnesses' affidavit which is included among the forms in this booklet also requires a notary public or a

lawyer to notarize the signature of the witnesses. This form is discussed in more detail in the next section. No

other form needs to be notarized. If you have legal questions, you should consult a lawyer.

Do I have to sign my advance directives in front of witnesses? Yes. You must sign the document in the

presence of two witnesses in order for any of the different types of advance directives to be valid. The

witnesses then sign the form.

For the living will and the appointment of health care agent, an optional form is provided in this booklet. It is

called a witnesses' affidavit. It is the witnesses' sworn statement that they saw you sign the living will or

appointment form and you were of sound mind and it was your free choice to do so. In the event that there is

a dispute regarding your living will or appointment of a health care agent, the witnesses affidavits support its

validity. This affidavit requires the use of an attorney or notary public.

Who can witness my signing of an advance directive? The person who you appoint to be your health care

agent or as your conservator cannot be a witness to your signature of the appointment form. In general, it is a

good idea not to have the person you name as your attorney-in-fact as a witness. Otherwise, except in a few

unique situations, Connecticut law does not state who may or may not be a witness to your advance directive.

Once I complete an advance directive what should I do? You should tell the following persons that you

have completed an advance directive and give them copies of the directives you have made:

•

your physician;

•

the person(s) you have named as a health care agent or as your attorney-in-fact for health care

decisions;

•

anyone who will make the existence of your advance directives known if you cannot do so yourself,

such as family members, close friends, your clergy or lawyer.

You should also bring copies when you are admitted to a hospital, nursing home or other health care facility.

The copies will be made part of your medical record.

THIS IS A SAMPLE AND OFFERED SOLELY FOR THE ASSISTANCE OF ATTORNEYS WHO WILL BE RESPONSIBLE FOR THE

ULTIMATE SUBSTANCE AND WORDING OF THE DOCUMENT. THE USE OF THIS SAMPLE BY PARTIES OTHER THAN ATTORNEYS

IS NOT AUTHORIZED

Living Will Form Page 4

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