Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care Page 2
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5Illinois Statutory Short Form
Power of Attorney for Health Care
1. I, _________________________________________________________________________________
(insert name and address of principal)
hereby revoke all prior powers of attorney for health care executed by me and appoint:
_____________________________________________________________________________________
(insert name and address of agent)
(NOTE: You may not name co−agents using this form.) 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.
A. 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 also shall have full power to authorize an autopsy and direct the disposition of my
remains.
B. Effective upon my death, my agent has the full power to make an anatomical gift of the following (initial
one):(NOTE: Initial one. In the event none of the options are initialed, then it shall be concluded that you do not
wish to grant your agent any such authority.)
______ Any organs, tissues or eyes suitable for transplantation or used for research or education
______ Specific organs: _________________________________________________________________
______ I do not grant my agent authority to make any anatomical gifts.
C. My agent also shall have full power to authorize an autopsy and direct the disposition of my remains. I intend
for this power of attorney to be in substantial compliance with Section 10 of the Disposition of Remains Act. All
decisions made by my agent with respect to the disposition of my remains, including cremation, shall be binding. I
hereby direct any cemetery organization, business operating a crematory or columbarium or both, funeral director
or embalmer, or funeral establishment who receives a copy of this document to act under it.
D. I intend for the person named as my agent 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, including records or
communications governed by the Mental Health and Developmental Disabilities Confidentiality Act. This release
authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996
(HIPAA) and regulations thereunder. I intend for the person named as my agent to serve as my "personal
representative" as that term is defined under HIPAA and regulations thereunder.
(i) The person named as my agent shall have the power to authorize the release of information governed by
HIPAA to third parties.
(ii) I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or
other covered health care provider, any insurance company and the Medical Informational Bureau Inc., or any
other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking
payment for me for such services to give, disclose and release to the person named as my agent, without
restriction, all of my individually identifiable 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, drug or alcohol abuse, and mental illness (including records or
communications governed by the Mental Health and Developmental Disabilities Confidentiality Act).
ILLINOIS STATUTORY
SHORT FORM POWER OF ATTORNEY
FOR HEALTH CARE
A5625
St. John’s Hospital· Springfield, Illinois 62769
Page 2 of 5
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