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