Illinois Living Will Declaration Template (Page 2 of 8) in pdf

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

SECTIONS 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 END

OF 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, ____________________________________ (insert name and address of principal),

hereby appoint:___________________________________________________________

(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.

America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR •

Illinois Living Will Declaration Template Page 2