Illinois Statutory Short Form Power Of Attorney For Health Care printable pdf download

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.

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

Illinois Statutory Short Form Power Of Attorney For Health Care