ILLINOIS
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE
(NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON
YOU DESIGNATE (YOUR “AGENT”) BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING POWER TO REQUIRE, CONSENT
TO, OR WITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT YOU TO OR
DISCHARGE YOU FROM ANY HOSPITAL, HOME, OR OTHER INSTITUTION. THIS FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED
POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH
THIS FORM AND KEEP A RECORD OF RECEIPTS, DISBURSEMENTS, AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS NOT ACTING PROPERLY. YOU MAY NAME SUCCESSOR AGENTS UNDER THIS FORM BUT NOT CO-AGENTS,
AND NO HEALTH CARE PROVIDER MAY BE NAMED. UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN THE MANNER PROVIDED BELOW,
UNTIL YOU REVOKE THIS POWER OR A COURT ACTING ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME DISABLED. THE POWERS YOU GIVE YOUR AGENT, YOUR RIGHT TO REVOKE THOSE POWERS,
AND THE PENALTIES FOR VIOLATING THE LAW ARE EXPLAINED MORE FULLY IN §§4-5, 4-6, 4-9, AND 4-10(b) OF THE ILLINOIS POWERS OF
ATTORNEY FOR HEALTH CARE LAW, OF WHICH THIS FORM IS A PART (SEE THE ATTACHMENT TO THIS FORM). THAT LAW EXPRESSLY PERMITS THE
USE OF ANY DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND,
YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.)
POWER OF ATTORNEY made this _____ day of _______________, ______.
(month)
(year)
1. I, ______________________________,
hereby appoint: _____________________________
(insert name and address
of principal)
(insert name and address of agent)
as my attorney-in-fact
(my “agent”) to act for me and in my name (in any way I could act in person) to make any and all decisions for
me concerning my personal care, medical treatment, hospitalization, and health care and to require, withhold, or withdraw
any type of medical treatment or procedure, even though my death may ensue. My agent shall have the same access to my medical
records that I have, including the right to disclose the contents to others. My agent shall also have full power to authorize
an autopsy and direct the disposition of my remains. Effective upon my death, my agent has the full power to make an anatomical
gift of the following (initial one):
______ Any organ.
______ Specific organs: ________________________________________________________
(THE ABOVE GRANT
OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY DECISION YOU COULD MAKE
TO OBTAIN OR TERMINATE ANY TYPE OF HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD AND WATER AND OTHER LIFE-SUSTAINING MEASURES,
IF YOUR AGENT BELIEVES SUCH ACTION WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU WISH TO LIMIT THE SCOPE OF YOUR
AGENT’S POWERS OR PRESCRIBE SPECIAL RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE AUTOPSY, OR DISPOSE
OF REMAINS, YOU MAY DO SO IN THE FOLLOWING PARAGRAPHS.)
2. The powers granted above shall not include the following powers or
shall be subject to the following rules or limitations (here you may include any specific limitations you deem appropriate,
such as: your own definition of when life-sustaining measures should be withheld; a direction to continue food and fluids
or life-sustaining treatment in all events; or instructions to refuse any specific types of treatment that are inconsistent
with your religious beliefs or unacceptable to you for any other reason, such as blood transfusion, electro-convulsive therapy,
amputation, psychosurgery, voluntary admission to a mental institution, etc.):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(THE SUBJECT OF
LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, SOME GENERAL STATEMENTS
CONCERNING THE WITHHOLDING OR REMOVAL OF LIFE-SUSTAINING TREATMENT ARE SET FORTH BELOW. IF YOU AGREE WITH ONE OF THESE STATEMENTS,
YOU MAY INITIAL THAT STATEMENT, BUT DO NOT INITIAL MORE THAN ONE):
I do not want my life to be prolonged nor do I want life-sustaining treatment
to be provided or continued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent
to consider the relief of suffering, the expense involved, and the quality as well as the possible extension of my life in
making decisions concerning life-sustaining treatment.
Initialed _________________________________
I want my life to be prolonged and I want life-sustaining treatment to
be provided or continued unless I am in a coma that my attending physician believes to be irreversible, in accordance with
reasonable medical standards at the time of reference. If and when I have suffered irreversible coma, I want life-sustaining
treatment to be withheld or discontinued.
Initialed _________________________________
I want my life to be prolonged to the greatest extent possible without
regard to my condition, the chances I have for recovery, or the cost of the procedures.
Initialed _________________________________
(THIS POWER OF
ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE MANNER PROVIDED IN §4-6 OF THE ILLINOIS POWERS OF ATTORNEY FOR HEALTH CARE
LAW (SEE THE BACK OF THIS FORM). ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY WILL BECOME
EFFECTIVE AT THE TIME THIS POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL GIFT, AUTOPSY, OR
DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR DURATION IS MADE BY INITIALING AND COMPLETING
EITHER OR BOTH OF THE FOLLOWING:)
3. ( ) This power of attorney shall become effective on ___________________________________
_____________________________________________________________________________________
(insert a future
date or event during your lifetime, such as court determination of your disability, when you want this power to first take
effect)
4. ( ) This power of attorney shall terminate on _________________________________________
_____________________________________________________________________________________
(insert a future
date or event, such as court determination of your disability, when you want this power to terminate prior to your death)
(IF YOU WISH TO
NAME SUCCESSOR AGENTS, INSERT THE NAMES AND ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)
5. If any agent named by me shall die, become incompetent, resign, refuse
to accept the office of agent, or be unavailable, I name the following (each to act alone and successively, in the order named)
as successors to such agent:
____________________________________________________________________________________
____________________________________________________________________________________
For purposes of
this paragraph 5, a person shall be considered to be incompetent if and while the person is a minor or an adjudicated incompetent
or disabled person or the person is unable to give prompt and intelligent consideration to health care matters, as certified
by a licensed physician.
(IF YOU WISH TO
NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, IN THE EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU MAY, BUT ARE NOT
REQUIRED TO, DO SO BY RETAINING THE FOLLOWING PARAGRAPH. THE COURT WILL APPOINT YOUR AGENT IF THE COURT FINDS THAT SUCH APPOINTMENT
WILL SERVE YOUR BEST INTERESTS AND WELFARE. STRIKE OUT PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT TO ACT AS GUARDIAN.)
6. If a guardian of my person is to be appointed, I nominate the agent
acting under this power of attorney as such guardian, to serve without bond or security.
7. I am fully informed as to all the contents of this form and understand
the full import of this grant of powers to my agent.
Signed ___________________________________
(principal)
The principal has had an opportunity to read the above form and has signed
the form or acknowledged his or her signature or mark on the form in my presence.
________________________________
Residing at: ______________________________
(witness)
(YOU MAY, BUT ARE
NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE AGENTS.)
Specimen signatures of
agent (and
I certify that the signature of my
successors)
agent (and successors) are correct.
___________________________________ ____________________________________
(agent)
(prinicpal)
___________________________________ ____________________________________
(successor
agent)
(prinicpal)
___________________________________ ____________________________________
(successor
agent)
(prinicpal)
SECTIONS
4-5, 4-6, 4-9, AND 4-10(b) OF THE POWERS OF ATTORNEY
FOR
HEALTH CARE LAW
(755
ILCS 45/4-5, 45/4-6, 45/4-9, AND 45/4-10(b))
§ 4-5. Limitations on health care agencies. Neither the attending physician
nor any other health care provider may act as agent under a health care agency; however, a person who is not administering
health care to the patient may act as health care agent for the patient even though the person is a physician or otherwise
licensed, certified, authorized, or permitted by law to administer health care in the ordinary course of business or the practice
of a profession.
§ 4-6. Revocation and amendment of health care agencies.
(a) Every health care agency may be revoked by the principal at any time,
without regard to the principal’s mental or physical condition, by any of the following methods:
1. By being
obliterated, burnt, torn or otherwise destroyed or defaced in a manner indicating intention to revoke;
2. By a
written revocation of the agency signed and dated by the principal or person acting at the direction of the principal; or
3. By an
oral or any other expression of the intent to revoke the agency in the presence of a witness 18 years of age or older who
signs and dates a writing confirming that such expression of intent was made.
(b) Every health care agency may be amended at any time by a written
amendment signed and dated by the principal or person acting at the direction of the principal.
(c) Any person, other than the agent, to whom a revocation or amendment
is communicated or delivered shall make all reasonable efforts to inform the agent of that fact as promptly as possible.
§ 4-9. Penalties. All persons shall be subject to the following sanctions
in relation to health care agencies, in addition to all other sanctions applicable under any other law or rule of professional
conduct:
(a) Any person shall be civilly liable who, without the principal’s
consent, wilfully conceals, cancels or alters a health care agency or any amendment or revocation of the agency or who falsifies
or forges a health care agency, amendment or revocation.
(b) A person who falsifies or forges a health care agency or wilfully
conceals or withholds personal knowledge of an amendment or revocation of a health care agency with the intent to cause a
withholding or withdrawal of life-sustaining or death-delaying procedures contrary to the intent of the principal and thereby,
because of such act, directly causes life-sustaining or death-delaying procedures to be withheld or withdrawn and death to
the patient to be hastened shall be subject to prosecution for involuntary manslaughter.
(c) Any person who requires or prevents execution of a health care agency
as a condition of insuring or providing any type of health care services to the patient shall be civilly liable and guilty
of a Class A misdemeanor.
§ 4-10. Statutory short form power of attorney for health care.
* *
*
(b) The statutory short form power of attorney for health care (the “statutory
health care power”) authorizes the agent to make any and all health care decisions on behalf of the principal which
the principal could make if present and under no disability, subject to any limitations on the granted powers that appear
on the face of the form, to be exercised in such manner as the agent deems consistent with the intent and desires of the principal.
The agent will be under no duty to exercise granted powers or to assume control of or responsibility for the principal’s
health care; but when granted powers are exercised, the agent will be required to use due care to act for the benefit of the
principal in accordance with the terms of the statutory health care power and will be liable for negligent exercise. The agent
may act in person or through others reasonably employed by the agent for that purpose but may not delegate authority to make
health care decisions. The agent may sign and deliver all instruments, negotiate and enter into all agreements and do all
other acts reasonably necessary to implement the exercise of the powers granted to the agent. Without limiting the generality
of the foregoing, the statutory health care power shall include the following powers, subject to any limitations appearing
on the face of the form:
(1) The agent is authorized to give consent to and authorize or refuse,
or to withhold or withdraw consent to, any and all types of medical care, treatment or procedures relating to the physical
or mental health of the principal, including any medication program, surgical procedures, life-sustaining treatment or provision
of food and fluids for the principal.
(2) The agent is authorized to admit the principal to or discharge the
principal from any and all types of hospitals, institutions, homes, residential or nursing facilities, treatment centers and
other health care institutions providing personal care or treatment for any type of physical or mental condition. The agent
shall have the same right to visit the principal in the hospital or other institution as is granted to a spouse or adult child
of the principal, any rule of the institution to the contrary notwithstanding.
(3) The agent is authorized to contract for any and all types of health
care services and facilities in the name of and on behalf of the principal and to bind the principal to pay for all such services
and facilities, and to have and exercise those powers over the principal’s property as are authorized under the statutory
property power, to the extent the agent deems necessary to pay health care costs; and the agent shall not be personally liable
for any services or care contracted for on behalf of the principal.
(4) At the principal’s expense and subject to reasonable rules
of the health care provider to prevent disruption of the principal’s health care, the agent shall have the same right
the principal has to examine and copy and consent to disclosure of all the principal’s medical records that the agent
deems relevant to the exercise of the agent’s powers, whether the records relate to mental health or any other medical
condition and whether they are in the possession of or maintained by any physician, psychiatrist, psychologist, therapist,
hospital, nursing home or other health care provider.
(5) The agent is authorized: to direct that an autopsy be made pursuant
to Section 2 of “An Act in relation to autopsy of dead bodies”, approved August 13, 1965, including all amendments;
to make a disposition of any part or all of the principal’s body pursuant to the Uniform Anatomical Gift Act, as now
or hereafter amended; and to direct the disposition of the principal’s remains.
