Illinois Statutory Short Form Power Of Attorney For Health Care (Page 6 of 7) in pdf

Illinois Statutory Short Form Power Of Attorney For Health Care Page 6

___ Staying alive is more important to me, no matter how sick I am, how much I am suffering,

the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be

prolonged to the greatest extent possible in accordance with reasonable medical standards.

SPECIFIC LIMITATIONS TO MY AGENT'S DECISION-MAKING AUTHORITY:

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. If

you wish to limit the scope of your agent's powers or prescribe special rules or limit the power to

authorize autopsy or dispose of remains, you may do so specifically in this form.

______________________________________________________________________________

My signature: _________________________________________

Today’s date: _________________________________________

HAVE YOUR WITNESS AGREE TO WHAT IS WRITTEN BELOW, AND THEN

COMPLETE THE SIGNATURE PORTION:

I am at least 18 years old. (check one of the options below):

___ I saw the principal sign this document, or

___ the principal told me that the signature or mark on the principal signature line is his or hers.

I am not the agent or successor agent(s) named in this document. I am not related to the principal,

the agent, or the successor agent(s) by blood, marriage, or adoption. I am not the principal's

physician, mental health service provider, or a relative of one of those individuals. I am not an

owner or operator (or the relative of an owner or operator) of the health care facility where the

principal is a patient or resident.

Witness printed name: ____________________________________________________________

Witness address: ________________________________________________________________

Witness signature: _______________________________________________________________

Today's date: ___________________________________________________________________

6 of 7

Illinois Statutory Short Form Power Of Attorney For Health Care Page 6