§4.01
APPOINTMENT OF HEALTH CARE REPRESENTATIVE
Contributed by Jack Reardon, J.D., LL.M., of Cipparone & Zaccaro, PC of New London,
CT.
Author’s Comments:
The following sample form Appointment of Health Care Representative is based
on CGS §19a-577. Additional or optional language to add to the statutory form is indicated with italics, and
includes among other things, the addition of HIPAA authorization language to grant access to privileged
medical records, and an alternate clause for designation of multiple successor agents.
[Note - § 19a-575a contains the combined form of document re health care instructions, appointment of
health care representative, designation of conservator for future incapacity and anatomical gift; In
comparison, § 19a-577 contains only language regarding appointment of health care representative.
However, § 19a-577 and 19-575a share identical language with respect to the appointment of health care
representative]. For related definitions and further details, refer to CGS §19a-570 et seq.
Section 19a-570(2) defines “Appointment of Health Care Representative" as a document executed in
accordance with section 19a-575a (a combination of multiple forms) or 19a-577 that appoints a health care
representative to make health care decisions for the declarant in the event the declarant becomes
incapacitated. Any person eighteen years of age or older may execute an Appointment of Health Care
Representative. The person appointed as representative cannot act as a witness to the execution of the
document or sign such document for the principal.
Certain persons are prohibited from being appointed as a health care representative. Pursuant to § 19a576(d), an operator, administrator or employee of a hospital, residential care home, rest home with nursing
supervision or chronic and convalescent nursing home may not be appointed as a health care
representative by any person who, at the time of the appointment, is a patient or a resident of, or has
applied for admission to, one of the foregoing facilities. An administrator or employee of a government
agency that is financially responsible for a person's medical care may not be appointed as a health care
representative for such person. This restriction does not apply if such operator, administrator or employee
is related to the principal by blood, marriage or adoption. Moreover, a physician cannot act as both health
care representative for a principal and attending physician for the principal.
An appointment of a health care representative becomes operative when the document is furnished to the
attending physician and the physician determines that the patient is incapacitated. An appointment of
health care representative may only be revoked by the declarant in a writing signed by the declarant and
two witnesses. The appointment of the declarant's spouse as health care representative is revoked upon
the divorce or legal separation of the declarant and spouse or upon the annulment or dissolution of their
marriage, unless the declarant specifies otherwise. The revocation of an appointment of health care
representative does not, of itself, revoke the living will of the declarant.
NOTE - If a declarant executes a Living Will in addition to the form Appointment of Health Care
Representative, the author recommends that the Appointment reference the Living Will and attach a copy
of the Living Will to the Appointment of Health Care Representative document.
Last revision: March 14, 2012
APPOINTMENT OF HEALTH CARE REPRESENTATIVE
I understand that, as a competent adult, I have the right to make decisions about my
health care. There may come a time when I am unable, due to incapacity, to make my
own health care decisions. In these circumstances, those caring for me will need
direction and will turn to someone who knows my values and health care wishes. By
signing this appointment of health care representative, I appoint a health care
representative with legal authority to make health care decisions on my behalf in such
case or at such time.
[additional language inserted by author] I intend this document to be an Appointment
of Health Care Representative as defined in Connecticut General Statutes § 19a-570 et
seq. Any ambiguity in this document shall be resolved in favor of qualifying this
document as such an Appointment of Health Care Representative.
I (Name of declarant) appoint .... (Name) 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 to reach and communicate an
informed decision regarding treatment, my health care representative is authorized to
(1) accept or refuse any treatment, service or procedure used to diagnose or treat my
physical or mental condition, except as otherwise provided by law, such as for
psychosurgery or shock therapy, as defined in section 17a-540, and (2) make the
decision to provide, withhold or withdraw life support systems. I direct my health care
representative to make decisions on my behalf in accordance with my wishes as stated
in a living will, 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.
[Choose either alternate 1 or 2 ]
[alternate 1- as set forth in statutory form] If this person is unwilling or unable to serve
as my health care representative, I appoint .... (Name) to be my alternative health care
representative.
[alternate 2 – language preferred by author] If for any reason (Name), is not available,
willing or competent to serve as my health care representative and is not expected to
become available, willing or competent to make a timely decision given my medical
circumstances, or if (he/she) is disqualified from acting on my behalf, I appoint the
following persons to serve as consecutive alternates to my health care representative
named above and who shall serve in the order specified below:
First Alternate:
(Name)
Second Alternate:
(Name)
Third Alternate:
(Name)
If any Alternate representative shall be unable or unwilling or unavailable to serve or to
continue to serve as my representative, the next Alternate representative named above
shall serve as my health care representative.
A written affidavit by either (Name agent 1) (Name alt. 1), (Name alt. 2), or (Name alt.
3), under oath, declaring that the prior designated representative(s) is(are) not
currently or expected to become available, willing or competent, will be conclusive
evidence of that alternate’s authority to act as my Agent under the terms of this
Appointment of Health Care Representative.
[END OF ALTERNATE 2]
[THE FOLLOWING IS ADDED LANGUAGE - NOT CONTAINED IN THE STATUTORY FORM
- GRANTING HIPAA AUTHORITY TO REPRESENTATIVE]
HIPAA RELEASE AUTHORITY
A.
I intend for my health care representative or alternate to be treated as I would
be with respect to my rights regarding the use and disclosure of my individually
identifiable health information or other medical records. This release authority applies
to any information governed by the Health Insurance Portability and Accountability Act
of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164, as amended.
B.
I authorize the following individuals or entities, i.e., any physician, healthcare
professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered
health care provider, any insurance company, and the Medical Information Bureau, Inc.,
or other health care clearinghouse that has provided treatment or services to me or
that has paid for or is seeking payment from me for such services: to give, disclose and
release to my Agent or Alternate, without restriction, all of my health information and
medical records regarding any past, present or future medical or mental health
condition, including all information relating to the diagnosis and treatment of HIV/AIDS,
sexually transmitted diseases, mental illness and drug or alcohol use.
C.
The authority given my Agent or Alternate shall supersede any prior agreement
that I may have made with my health care providers to restrict access to or disclosure
of my individually identifiable health information. The authority given my Agent or
Alternate has no expiration date and shall expire only in the event that I revoke this
authority in writing and deliver such revocation to my health care provider.
[END OF ADDED HIPAA AUTHORITY LANGUAGE]
This request is made, after careful reflection, while I am of sound mind.
.... (Signature)
.... (Date)
This document was signed in our presence, by the above-named .... (Name) who
appeared to be eighteen years of age or older, of sound mind and able to understand
the nature and consequences of health care decisions at the time the document was
signed.
.... (Witness)
.... (Address)
.... (Witness)
.... (Address)
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