How to Fill Out and Submit the Connecticut Health Care Proxy Form

Connecticut’s health care proxy form, officially called the Appointment of Health Care Representative, lets you name an adult who can make medical decisions for you if a doctor determines you can no longer make them yourself. You can download it free from the state, fill in your representative’s name, sign it in front of two witnesses, and hand copies to your doctors and the person you chose. No lawyer or notary is required.

Where to Get the Form

Connecticut publishes two versions at no cost. The Office of the Attorney General offers a standalone form on its health-issues page.¹ The Department of Public Health hosts its own version with slightly different formatting.² Either is legally valid.

If you also want a living will, an anatomical gift designation, and a conservator appointment in a single document, the longer combined form laid out in C.G.S. § 19a-575a does all of that at once.³ For most people, the standalone proxy is enough.

Who You Can Name as Your Representative

Any adult 18 or older can serve.⁴ Most people pick a spouse, adult child, sibling, or close friend who knows their views on medical care. Two statutory restrictions apply.

If you are a patient or resident of a hospital, residential care home, rest home with nursing supervision, or chronic and convalescent nursing home, or you have applied for admission to one, you cannot name an operator, administrator, or employee of that facility. The same bar applies to an administrator or employee of a government agency financially responsible for your care. Both restrictions lift if the person is related to you by blood, marriage, or adoption.⁴

A physician or advanced practice registered nurse cannot serve as both your representative and your attending provider at the same time.⁴ A doctor who isn’t treating you can still be your representative.

Filling Out the Form

The DPH version runs two pages. Page one is the legally operative document; page two is an optional notarized affidavit.²

Name Your Primary Representative

Write your representative’s full name in the first blank. The form’s authorization clause gives that person the power to accept or refuse any treatment on your behalf once your attending physician determines you are incapacitated. That authority reaches life-sustaining treatment. It does not reach psychosurgery or shock therapy, which are excluded by law.

Name an Alternative

A second blank lets you appoint a backup who steps in if your primary representative is unwilling or unable to serve.³ Leaving this blank is allowed, but if your primary can’t be reached in an emergency, no one else will have documented authority to act.

Add Your Instructions

The form directs your representative to follow your wishes as expressed in a living will or otherwise known to them. Where your wishes are unclear or a situation arises you didn’t anticipate, the representative makes a best-interests decision based on what they know about your values.²

You can attach a separate page with specific preferences about resuscitation, artificial nutrition, ventilators, pain management, or religious considerations, or use the longer § 19a-575a document, which has dedicated space for living-will instructions and pregnancy-related preferences.³ Concrete language beats vague language. “I do not want mechanical ventilation if I am permanently unconscious” gives providers a clear mandate; “no heroic measures” doesn’t.

Signing and Witnesses

Sign and date the form in front of two adult witnesses, who also sign.⁴ The witnesses attest that you appeared to be of sound mind and acting voluntarily, and they provide their signatures and addresses.

Your named representative and alternative cannot serve as witnesses.⁴

Notarization is not required. Two witnesses are enough to make the form legally effective.⁴ Notarizing the witnesses’ signatures on page two of the DPH form is optional and can help head off later disputes about whether the witnesses actually saw you sign.

When Your Representative Can Actually Act

Signing the form does not transfer decision-making power right away. Two things have to happen. The completed document must reach your attending physician or advanced practice registered nurse. And that provider must determine that you are incapacitated, meaning you cannot understand the nature and consequences of health care decisions and cannot reach and communicate an informed choice about treatment.⁵

Until both conditions are met, you keep full authority over your own care. If you later regain capacity, your representative’s authority suspends automatically.

Getting Copies to the Right People

The form does nothing until it reaches your medical providers. Distribute copies to:

Your representative and alternative. Both should keep a copy at home and a photo or scan on their phone so they can produce it at a hospital.
Your primary care physician. Ask the office to scan it into your electronic health record so any provider in the same system can see it.
Specialists and facilities where you receive regular care, including hospitals, dialysis centers, and long-term care facilities.

Keep the signed original somewhere your representative can access quickly, such as a home filing cabinet or fireproof document box. A safe-deposit box is a poor choice because banks have limited hours. Review your storage plan once a year to make sure it still reflects where you receive care.

Changing or Revoking Your Appointment

You can revoke the appointment at any time, but the revocation must be in writing and signed by you and two witnesses. A verbal statement alone is not enough. Once you sign the revocation, your attending physician or other provider adds it to your medical record.⁵

To switch representatives, the simplest path is to execute a new form. The new document supersedes the old one. Distribute the replacement to every provider and facility that has the original.

Revoking your representative does not revoke a living will you signed separately. The two documents are independent.⁵

Divorce Revokes the Appointment Automatically

If you named your spouse and you later divorce, legally separate, or have your marriage annulled or dissolved, the appointment is automatically revoked unless the document says otherwise.⁵ If you still want your former spouse to serve after a divorce, you need to sign a new form naming them again.

What Happens If You Skip the Form

Without a completed form, Connecticut law still provides a path for medical decisions when you are incapacitated, but you lose control over who fills the role. Your attending physician consults your next of kin following a statutory priority order: spouse first, then adult children, parents, adult siblings, and grandparents.⁵ The physician also weighs any statements you made to them and to anyone else the physician knows you spoke with about your wishes.

That default works, but it can produce conflict when relatives disagree. Filling out the form puts one person you chose in charge, and for anyone with strong preferences about end-of-life care, that clarity is the whole point.

1
Office of the Attorney General. Connecticut’s Living Will Laws
2
Connecticut Department of Public Health. Appointment of Health Care Representative
3
Justia. Connecticut Code 19a-575a – Form of Document Re Health Care Instructions, Appointment of Health Care Representative, Designation of Conservator for Future Incapacity and Anatomical Gift
4
Justia. Connecticut Code 19a-576 – Appointment of Health Care Representative
5
Connecticut General Assembly. Connecticut Code Chapter 368w – Removal of Life Support Systems and Medical Orders for Life-Sustaining Treatment