Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care (Page 3 of 5) in pdf

ILLINOIS STATUTORY

SHORT FORM POWER OF ATTORNEY

FOR HEALTH CARE

(iii) The authority given to the person named as my agent shall supersede any prior agreement that I may have

with my health care providers to restrict access to, or disclosure of, my individually identifiable health information.

The authority given to the person named as my agent has no expiration date and shall expire only in the event

that I revoke the authority in writing and deliver it to my health care provider. (NOTE: The above grant of power is

intended to be as broad as possible so that your agent will have the 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:

(NOTE: 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.)

__________________________________________________________________________________________

(NOTE: 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. These statements serve as guidance for your agent, who shall give careful consideration to the statement

you initial when engaging in health care decision−making on your behalf.)

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 which my attending physician believes to be irreversible, in the opinion of my attending physician, in

accordance with reasonable medical standards at the time of reference, in a state of "permanent

unconsciousness" or suffer from an "incurable or irreversible condition" or "terminal condition," as those terms are

defined in Section 4−4 of theIllinois Power of Attorney Act. If and when I am in any one of these states or

conditions, I have suffered irreversible coma, I want life−sustaining treatment to be withheld or discontinued.

Initialed ________

A5625

Rev. 09/01/2011

800 E. Carpenter Street · Springfield, Illinois 62769

Page 3 of 5

Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care Page 3