|
Public Act 097-0148
|
| SB1877 Enrolled | LRB097 09886 AJO 50046 b |
|
|
AN ACT concerning civil law.
|
Be it enacted by the People of the State of Illinois,
|
represented in the General Assembly:
|
Section 5. The Illinois Power of Attorney Act is amended by |
changing Section 4-10 as follows:
|
(755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10)
|
(Text of Section before amendment by P.A. 96-1195)
|
Sec. 4-10. Statutory short form power of attorney for |
health care.
|
(a) The following form (sometimes also referred to in this |
Act as the
"statutory health care power") may be used to grant |
an agent powers with
respect to the principal's own health |
care; but the statutory health care
power is not intended to be |
exclusive nor to cover delegation of a parent's
power to |
control the health care of a minor child, and no provision of |
this
Article shall be construed to invalidate or bar use by the |
principal of any
other or
different form of power of attorney |
for health care. Nonstatutory health
care powers must be
|
executed by the principal, designate the agent and the agent's |
powers, and
comply with Section 4-5 of this Article, but they |
need not be witnessed or
conform in any other respect to the |
statutory health care power. When a
power of attorney in |
substantially the
following form is used, including the |
|
"notice" paragraph at the beginning
in capital letters, it |
shall have the meaning and effect prescribed in this
Act. The |
statutory health care power may be included in or
combined with |
any
other form of power of attorney governing property or other |
matters.
|
"ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH |
CARE
|
(NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE |
THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE |
HEALTH CARE DECISIONS FOR YOU,
INCLUDING POWER TO REQUIRE, |
CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL
CARE OR MEDICAL |
TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT
YOU |
TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER |
INSTITUTION. THIS
FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO |
EXERCISE GRANTED POWERS; BUT
WHEN POWERS ARE EXERCISED, YOUR |
AGENT WILL HAVE TO USE
DUE CARE TO ACT FOR
YOUR BENEFIT AND IN |
ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF
RECEIPTS, |
DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT
|
CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS |
NOT ACTING PROPERLY. YOU MAY
NAME SUCCESSOR AGENTS UNDER THIS |
FORM
BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE |
NAMED. UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER
IN |
THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A |
COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY |
EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN |
AFTER YOU BECOME DISABLED. THE POWERS YOU
GIVE YOUR AGENT, YOUR |
|
RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR
VIOLATING |
THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND
|
4-10(b) OF THE ILLINOIS
"POWERS OF ATTORNEY FOR HEALTH CARE |
LAW"
OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM). |
THAT LAW
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF |
POWER OF ATTORNEY YOU
MAY DESIRE. IF THERE IS ANYTHING ABOUT |
THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER |
TO EXPLAIN IT TO YOU.)
|
POWER OF ATTORNEY made this .......................day of
|
................................
|
(month) (year)
|
1. I, ..................................................,
|
(insert name and address of principal)
|
hereby appoint:
|
............................................................
|
(insert name and address of agent)
|
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. 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 shall |
also have full power to
authorize an autopsy and direct the |
disposition of my remains.
Effective upon my death, my agent |
|
has the full power to make an anatomical
gift of the following |
(initial one):
|
....Any organs, tissues, or eyes suitable for |
transplantation or used for
research or education.
|
....Specific organs:.................................
|
(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS |
POSSIBLE SO THAT
YOUR AGENT WILL HAVE 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 (here 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.):
|
.............................................................
|
.............................................................
|
.............................................................
|
.............................................................
|
.............................................................
|
(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):
|
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 |
accordance with reasonable medical
standards at the time of |
reference. If and when I have suffered
irreversible coma, I |
want life-sustaining treatment to be withheld or
discontinued.
|
|
Initialed...........................
|
I want my life to be prolonged to the greatest extent |
possible without
regard to my condition, the chances I have for |
recovery or the cost of the
procedures.
|
Initialed...........................
|
(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE |
MANNER
PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF |
ATTORNEY FOR HEALTH CARE
LAW" (SEE THE BACK OF THIS FORM). |
ABSENT AMENDMENT OR
REVOCATION, THE AUTHORITY GRANTED IN THIS
|
POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER |
IS SIGNED
AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF |
ANATOMICAL GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS |
AUTHORIZED, UNLESS A LIMITATION ON THE
BEGINNING DATE OR |
DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR
BOTH OF |
THE FOLLOWING:)
|
3. ( ) This power of attorney shall become effective on
|
.............................................................
|
.............................................................
|
(insert a future date or event during your lifetime, such as |
court
determination of your disability, when you want this |
power to first take
effect)
|
4. ( ) This power of attorney shall terminate on
.......
|
.............................................................
|
(insert a future date or event, such as court determination of |
your
disability, when you want this power to terminate prior to |
your death)
|
|
(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND |
ADDRESSES OF
SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)
|
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.
(IF YOU |
WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON,
IN THE |
EVENT A COURT DECIDES
THAT ONE SHOULD BE APPOINTED, YOU MAY, |
BUT ARE NOT REQUIRED TO, DO SO BY
RETAINING THE FOLLOWING
|
PARAGRAPH. THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS |
THAT SUCH
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 without bond or security.
|
7. I am fully informed as to all the contents of this form |
and
understand the full import of this grant of powers to my |
agent.
|
|
Signed..............................
|
(principal)
|
The principal has had an opportunity to read the above form |
and has
signed the form or acknowledged his or her signature or |
mark on the form in my presence.
|
.......................... Residing at......................
|
(witness)
|
(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND |
SUCCESSOR AGENTS
TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU |
INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST |
COMPLETE THE CERTIFICATION OPPOSITE THE
SIGNATURES OF THE |
AGENTS.)
|
Specimen signatures of I certify that the signatures of my
|
agent (and successors). agent (and successors) are correct.
|
....................... ...................................
|
(agent) (principal)
|
....................... ...................................
|
(successor agent) (principal)
|
....................... ...................................
|
(successor agent) (principal)"
|
(b) The statutory short form power of attorney for health |
care (the
"statutory health care power") authorizes the agent |
to make any and all
health care decisions on behalf of the |
principal which the principal could
make if present and under |
no disability, subject to any limitations on the
granted powers |
that appear on the face of the form, to be exercised in such
|
|
manner as the agent deems consistent with the intent and |
desires of the
principal. The agent will be under no duty to |
exercise granted powers or
to assume control of or |
responsibility for the principal's health care;
but when |
granted powers are exercised, the agent will be required to use
|
due care to act for the benefit of the principal in accordance |
with the
terms of the statutory health care power and will be |
liable
for negligent exercise. The agent may act in person or |
through others
reasonably employed by the agent for that |
purpose
but may not delegate authority to make health care |
decisions. The agent
may sign and deliver all instruments, |
negotiate and enter into all
agreements and do all other acts |
reasonably necessary to implement the
exercise of the powers |
granted to the agent. Without limiting the
generality of the |
foregoing, the statutory health care power shall include
the |
following powers, subject to any limitations appearing on the |
face of the form:
|
(1) The agent is authorized to give consent to and |
authorize or refuse,
or to withhold or withdraw consent to, |
any and all types of medical care,
treatment or procedures |
relating to the physical or mental health of the
principal, |
including any medication program, surgical procedures,
|
life-sustaining treatment or provision of food and fluids |
for the principal.
|
(2) The agent is authorized to admit the principal to |
or discharge the
principal from any and all types of |
|
hospitals, institutions, homes,
residential or nursing |
facilities, treatment centers and other health care
|
institutions providing personal care or treatment for any |
type of physical
or mental condition. The agent shall have |
the same right to visit the
principal in the hospital or |
other institution as is granted to a spouse or
adult child |
of the principal, any rule of the institution to the |
contrary
notwithstanding.
|
(3) The agent is authorized to contract for any and all |
types of health
care services and facilities in the name of |
and on behalf of the principal
and to bind the principal to |
pay for all such services and facilities,
and to have and |
exercise those powers over the principal's property as are
|
authorized under the statutory property power, to the |
extent the agent
deems necessary to pay health care costs; |
and
the agent shall not be personally liable for any |
services or care contracted
for on behalf of the principal.
|
(4) At the principal's expense and subject to |
reasonable rules of the
health care provider to prevent |
disruption of the principal's health care,
the agent shall |
have the same right the principal has to examine and copy
|
and consent to disclosure of all the principal's medical |
records that the agent deems
relevant to the exercise of |
the agent's powers, whether the records
relate to mental |
health or any other medical condition and whether they are |
in
the possession of or maintained by any physician, |
|
psychiatrist,
psychologist, therapist, hospital, nursing |
home or other health care
provider.
|
(5) The agent is authorized: to direct that an autopsy |
be made pursuant
to Section 2 of "An Act in relation to |
autopsy of dead bodies", approved
August 13, 1965, |
including all amendments;
to make a disposition of any
part |
or all of the principal's body pursuant to the Illinois |
Anatomical Gift
Act, as now or hereafter amended; and to |
direct the disposition of the
principal's remains.
|
(Source: P.A. 93-794, eff. 7-22-04.)
|
(Text of Section after amendment by P.A. 96-1195)
|
Sec. 4-10. Statutory short form power of attorney for |
health care.
|
(a) The form prescribed in this Section (sometimes also |
referred to in this Act as the
"statutory health care power") |
may be used to grant an agent powers with
respect to the |
principal's own health care; but the statutory health care
|
power is not intended to be exclusive nor to cover delegation |
of a parent's
power to control the health care of a minor |
child, and no provision of this
Article shall be construed to |
invalidate or bar use by the principal of any
other or
|
different form of power of attorney for health care. |
Nonstatutory health
care powers must be
executed by the |
principal, designate the agent and the agent's powers, and
|
comply with Section 4-5 of this Article, but they need not be |
|
witnessed or
conform in any other respect to the statutory |
health care power. When a
power of attorney in substantially |
the
form prescribed in this Section is used, including the |
"Notice to the Individual Signing the Illinois Statutory Short |
Form Power of Attorney for Health Care" (or "Notice" |
paragraphs) at the beginning of the form on a separate sheet in |
14-point type, it shall have the meaning and effect prescribed |
in this
Act. A power of attorney for health care shall be |
deemed to be in substantially the same format as the statutory |
form if the explanatory language throughout the form (the |
language following the designation "NOTE:") is distinguished |
in some way from the legal paragraphs in the form, such as the |
use of boldface or other difference in typeface and font or |
point size, even if the "Notice" paragraphs at the beginning |
are not on a separate sheet of paper or are not in 14-point |
type, or if the principal's initials do not appear in the |
acknowledgement at the end of the "Notice" paragraphs. The |
statutory health care power may be included in or
combined with |
any
other form of power of attorney governing property or other |
matters.
|
(b) The Illinois Statutory Short Form Power of Attorney for |
Health Care shall be substantially as follows:
|
"NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS |
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE
|
|
PLEASE READ THIS NOTICE CAREFULLY. The form that you will |
be signing is a legal document. It is governed by the Illinois |
Power of Attorney Act. If there is anything about this form |
that you do not understand, you should ask a lawyer to explain |
it to you. |
The purpose of this Power of Attorney is to give your |
designated "agent" broad powers to make health care decisions |
for you, including the power to require, consent to, or |
withdraw treatment for any physical or mental condition, and to |
admit you or discharge you from any hospital, home, or other |
institution. You may name successor agents under this form, but |
you may not name co-agents. |
This form does not impose a duty upon your agent to make |
such health care decisions, so it is important that you select |
an agent who will agree to do this for you and who will make |
those decisions as you would wish. It is also important to |
select an agent whom you trust, since you are giving that agent |
control over your medical decision-making, including |
end-of-life decisions. Any agent who does act for you has a |
duty to act in good faith for your benefit and to use due care, |
competence, and diligence. He or she must also act in |
accordance with the law and with the statements in this form. |
Your agent must keep a record of all significant actions taken |
as your agent. |
Unless you specifically limit the period of time that this |
Power of Attorney will be in effect, your agent may exercise |
|
the powers given to him or her throughout your lifetime, even |
after you become disabled. A court, however, can take away the |
powers of your agent if it finds that the agent is not acting |
properly. You may also revoke this Power of Attorney if you |
wish. |
The Powers you give your agent, your right to revoke those |
powers, and the penalties for violating the law are explained |
more fully in Sections 4-5, 4-6, and 4-10(c) 4-10(b) of the |
Illinois Power of Attorney Act. This form is a part of that |
law. The "NOTE" paragraphs throughout this form are |
instructions. |
You are not required to sign this Power of Attorney, but it |
will not take effect without your signature. You should not |
sign it if you do not understand everything in it, and what |
your agent will be able to do if you do sign it.
|
Please put your initials on the following line indicating |
that you have read this Notice: |
......................
|
(Principal's initials)"
|
"ILLINOIS 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. |
B.
Effective upon my death, my agent has the full power to |
make an anatomical
gift of the following: |
(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 shall also 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). |
(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. The |
authority given to the person named as my agent to serve as my |
"personal representative" as defined under HIPAA and |
regulations thereunder and to access my individually |
identifiable health information or authorize the release of the |
same to third parties shall take effect immediately, even if I |
designate in Paragraph 3 of this document that this agency |
shall otherwise take effect at some future date. |
(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: Here 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 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 the Illinois Power |
of Attorney Act. If and when I am in any one of these states or |
conditions, I want life-sustaining treatment to be withheld or
|
|
discontinued.
|
Initialed ...........................
|
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. Your agent can act immediately, unless you |
specify otherwise; but you cannot specify otherwise with |
respect to your "personal representative" under subparagraph |
D(iii).)
|
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 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 without bond or security.
|
7. I am fully informed as to all the contents of this form |
and
understand the full import of this grant of powers to my |
agent.
|
Dated: ..........
|
Signed ..............................
|
(principal's signature or mark)
|
The principal has had an opportunity to review the above |
form and has
signed the form or acknowledged his or her |
signature or mark on the form in my presence. The undersigned |
witness certifies that the witness is not: (a) the attending |
physician or mental health service provider or a relative of |
the physician or provider; (b) an owner, operator, or relative |
of an owner or operator of a health care facility in which the |
principal is a patient or resident; (c) a parent, sibling, |
descendant, or any spouse of such parent, sibling, or |
descendant of either the principal or any agent or successor |
agent under the foregoing power of attorney, whether such |
relationship is by blood, marriage, or adoption; or (d) an |
agent or successor agent under the foregoing power of attorney.
|
.......................
|
(Witness Signature)
|
|
.......................
|
(Print Witness Name)
|
.......................
|
(Street Address)
|
.......................
|
(City, State, ZIP)
|
(NOTE: You may, but are not required to, request your agent and |
successor agents to provide specimen signatures below. If you |
include specimen signatures in this power of attorney, you must |
complete the certification opposite the signatures of the |
agents.)
|
Specimen signatures of I certify that the signatures of my
|
agent (and successors). agent (and successors) are correct.
|
....................... ...................................
|
(agent) (principal)
|
....................... ...................................
|
(successor agent) (principal)
|
....................... ...................................
|
(successor agent) (principal)"
|
(NOTE: The name, address, and phone number of the person |
preparing this form or who assisted the principal in completing |
this form is optional.) |
.........................
|
(name of preparer)
|
.........................
|
|
.........................
|
(address)
|
.........................
|
(phone)
|
(c) The statutory short form power of attorney for health |
care (the
"statutory health care power") authorizes the agent |
to make any and all
health care decisions on behalf of the |
principal which the principal could
make if present and under |
no disability, subject to any limitations on the
granted powers |
that appear on the face of the form, to be exercised in such
|
manner as the agent deems consistent with the intent and |
desires of the
principal. The agent will be under no duty to |
exercise granted powers or
to assume control of or |
responsibility for the principal's health care;
but when |
granted powers are exercised, the agent will be required to use
|
due care to act for the benefit of the principal in accordance |
with the
terms of the statutory health care power and will be |
liable
for negligent exercise. The agent may act in person or |
through others
reasonably employed by the agent for that |
purpose
but may not delegate authority to make health care |
decisions. The agent
may sign and deliver all instruments, |
negotiate and enter into all
agreements and do all other acts |
reasonably necessary to implement the
exercise of the powers |
granted to the agent. Without limiting the
generality of the |
foregoing, the statutory health care power shall include
the |
following powers, subject to any limitations appearing on the |
|
face of the form:
|
(1) The agent is authorized to give consent to and |
authorize or refuse,
or to withhold or withdraw consent to, |
any and all types of medical care,
treatment or procedures |
relating to the physical or mental health of the
principal, |
including any medication program, surgical procedures,
|
life-sustaining treatment or provision of food and fluids |
for the principal.
|
(2) The agent is authorized to admit the principal to |
or discharge the
principal from any and all types of |
hospitals, institutions, homes,
residential or nursing |
facilities, treatment centers and other health care
|
institutions providing personal care or treatment for any |
type of physical
or mental condition. The agent shall have |
the same right to visit the
principal in the hospital or |
other institution as is granted to a spouse or
adult child |
of the principal, any rule of the institution to the |
contrary
notwithstanding.
|
(3) The agent is authorized to contract for any and all |
types of health
care services and facilities in the name of |
and on behalf of the principal
and to bind the principal to |
pay for all such services and facilities,
and to have and |
exercise those powers over the principal's property as are
|
authorized under the statutory property power, to the |
extent the agent
deems necessary to pay health care costs; |
and
the agent shall not be personally liable for any |
|
services or care contracted
for on behalf of the principal.
|
(4) At the principal's expense and subject to |
reasonable rules of the
health care provider to prevent |
disruption of the principal's health care,
the agent shall |
have the same right the principal has to examine and copy
|
and consent to disclosure of all the principal's medical |
records that the agent deems
relevant to the exercise of |
the agent's powers, whether the records
relate to mental |
health or any other medical condition and whether they are |
in
the possession of or maintained by any physician, |
psychiatrist,
psychologist, therapist, hospital, nursing |
home or other health care
provider.
|
(5) The agent is authorized: to direct that an autopsy |
be made pursuant
to Section 2 of "An Act in relation to |
autopsy of dead bodies", approved
August 13, 1965, |
including all amendments;
to make a disposition of any
part |
or all of the principal's body pursuant to the Illinois |
Anatomical Gift
Act, as now or hereafter amended; and to |
direct the disposition of the
principal's remains.
|
(Source: P.A. 96-1195, eff. 7-1-11.)
|
Section 99. Effective date. This Act takes effect July 1, |
2011.
|