Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care (Page 4 of 5) in pdf

ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE.

I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical

standards without regard to my condition, the chances I have for recovery or the cost of the procedures

Initialed ________

(NOTE: This power of attorney may be amended or revoked by you in the manner provided in Section 4−6 of the

Illinois Power of Attorney Act.)

3. ( ) This power of attorney shall become effective on __________________________________________

______________________________________________________________________________________

(NOTE: Insert a future date or event during your lifetime, such as a court determination of your disability or a

written determination by your physician that you are incapacitated, when you want this power to first take effect.)

(NOTE: If you do not amend or revoke this power, or if you do not specify a specific ending date in paragraph 4,

it will remain in effect until your death; except that your agent will still have the authority to donate your organs,

authorize an autopsy, and dispose of your remains after your death, if you grant that authority to your agent.)

4. ( ) This power of attorney shall terminate on ________________________________________________

_____________________________________________________________________________________

(NOTE: Insert a future date or event, such as a court determination that you are not under a legal disability or a

written determination by your physician that you are not incapacitated, if of your disability, when you want this

power to terminate prior to your death.)

(NOTE : You cannot use this form to name co −agents. If you wish to name successor agents, insert the names

and addresses of the successors in paragraph 5.)

5. If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be

unavailable, I name the following (each to act alone and successively, in the order named) as successors to such

agent :

_______________________________________________________________________________________

For purposes of this paragraph 5, a person shall be considered to be incompetent if and while the person is a

minor, or an adjudicated incompetent or disabled person, or the person is unable to give prompt and intelligent

consideration to health care matters, as certified by a licensed physician.

(NOTE: If you wish to, you may name your agent as guardian of your person if a court decides that one should

be appointed. To do this, retain paragraph 6, and the court will appoint your agent if the court finds that this

appointment will serve your best interests and welfare. Strike out paragraph 6 if you do not want your agent to

act as guardian.)

6. If a guardian of my person is to be appointed, I nominate the agent acting under this power of attorney as such

guardian, to serve with out bond or security.

ILLINOIS STATUTORY

SHORT FORM POWER OF ATTORNEY

FOR HEALTH CARE

A5625

St. John’s Hospital· Springfield, Illinois 62769

Page 4 of 5

Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care Page 4