Illinois Statutory Short Form Power Of Attorney For Health Care (Page 4 of 7) in pdf

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

(iii) There is no need to have the form notarized.

(iv) Give a copy to your agent and to each of your successor agents.

(v) Give another copy to your physician.

(vi) Take a copy with you when you go to the hospital.

(vii) Show it to your family and friends and others who care for you.

WHAT IF I CHANGE MY MIND?

You may change your mind at any time. If you do, tell someone who is at least 18 years old that

you have changed your mind, and/or destroy your document and any copies. If you wish, fill out a

new form and make sure everyone you gave the old form to has a copy of the new one, including,

but not limited to, your agents and your physicians.

WHAT IF I DO NOT WANT TO USE THIS FORM?

In the event you do not want to use the Illinois statutory form provided here, any document you

complete must be executed by you, designate an agent who is over 18 years of age and not

prohibited from serving as your agent, and state the agent's powers, but it need not be witnessed

or conform in any other respect to the statutory health care power.

If you have questions about the use of any form, you may want to consult your physician, other

health care provider, and/or an attorney.

MY POWER OF ATTORNEY FOR HEALTH CARE

THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY FOR

HEALTH CARE. (You must sign this form and a witness must also sign it before it is valid)

My name (Print your full name): __________________________________________________

My address: ___________________________________________________________________

I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT (an agent is your

personal representative under state and federal law):

(Agent name) __________________________________________________________________

(Agent address) _________________________________________________________________

(Agent phone number) ___________________________________________________________

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