Illinois General Assembly - Full Text of HB2373
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Full Text of HB2373  98th General Assembly




State of Illinois
2013 and 2014


Introduced , by Rep. Ann Williams


755 ILCS 45/4-4  from Ch. 110 1/2, par. 804-4
755 ILCS 45/4-5.1
755 ILCS 45/4-10  from Ch. 110 1/2, par. 804-10

    Amends the Illinois Power of Attorney Act. Replaces the statutory short form power of attorney for health care and the notice to the individual signing the power of attorney for health care. Defines "health care agent" and deletes the definitions of "incurable or irreversible condition", "permanent unconsciousness", and "terminal condition". Provides that no witness to the signing of a health care agency may be under 18 years of age. Provides that nonstatutory health care powers must meet certain criteria.

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HB2373LRB098 04014 HEP 34034 b

1    AN ACT concerning civil law.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Power of Attorney Act is amended by
5changing Sections 4-4, 4-5.1, and 4-10 as follows:
6    (755 ILCS 45/4-4)  (from Ch. 110 1/2, par. 804-4)
7    Sec. 4-4. Definitions. As used in this Article:
8    (a) "Attending physician" means the physician who has
9primary responsibility at the time of reference for the
10treatment and care of the patient.
11    (b) "Health care" means any care, treatment, service or
12procedure to maintain, diagnose, treat or provide for the
13patient's physical or mental health or personal care.
14    (c) "Health care agency" means an agency governing any type
15of health care, anatomical gift, autopsy or disposition of
16remains for and on behalf of a patient and refers to the power
17of attorney or other written instrument defining the agency or
18the agency, itself, as appropriate to the context.
19    (d) "Health care provider" or "provider" means the
20attending physician and any other person administering health
21care to the patient at the time of reference who is licensed,
22certified, or otherwise authorized or permitted by law to
23administer health care in the ordinary course of business or



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1the practice of a profession, including any person employed by
2or acting for any such authorized person.
3    (e) "Patient" means the principal or, if the agency governs
4health care for a minor child of the principal, then the child.
5    (e-5) "Health care agent" means an individual at least 18
6years old designated by a person to make health care decisions
7of any type, including, but not limited to, anatomical gift,
8autopsy, or disposition of remains for and on behalf of the
9individual. A health care agent is a personal representative
10under State and federal law, but may not be the principal's
11physician or health care provider.
12    (f) (Blank). "Incurable or irreversible condition" means
13an illness or injury (i) for which there is no reasonable
14prospect of cure or recovery, (ii) that ultimately will cause
15the patient's death even if life-sustaining treatment is
16initiated or continued, (iii) that imposes severe pain or
17otherwise imposes an inhumane burden on the patient, or (iv)
18for which initiating or continuing life-sustaining treatment,
19in light of the patient's medical condition, provides only
20minimal medical benefit.
21    (g) (Blank). "Permanent unconsciousness" means a condition
22that, to a high degree of medical certainty, (i) will last
23permanently, without improvement, (ii) in which thought,
24sensation, purposeful action, social interaction, and
25awareness of self and environment are absent, and (iii) for
26which initiating or continuing life-sustaining treatment, in



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1light of the patient's medical condition, provides only minimal
2medical benefit. For the purposes of this definition, "medical
3benefit" means a chance to cure or reverse a condition.
4    (h) (Blank). "Terminal condition" means an illness or
5injury for which there is no reasonable prospect of cure or
6recovery, death is imminent, and the application of
7life-sustaining treatment would only prolong the dying
9(Source: P.A. 96-1195, eff. 7-1-11.)
10    (755 ILCS 45/4-5.1)
11    Sec. 4-5.1. Limitations on who may witness health care
13    (a) Every health care agency shall bear the signature of a
14witness to the signing of the agency. No witness may be under
1518 years of age. None of the following may serve as a witness
16to the signing of a health care agency:
17        (1) the attending physician or mental health service
18    provider of the principal, or a relative of the physician
19    or provider;
20        (2) an owner, operator, or relative of an owner or
21    operator of a health care facility in which the principal
22    is a patient or resident;
23        (3) a parent, sibling, or descendant, or the spouse of
24    a parent, sibling, or descendant, of either the principal
25    or any agent or successor agent, regardless of whether the



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1    relationship is by blood, marriage, or adoption;
2        (4) an agent or successor agent for health care.
3    (b) The prohibition on the operator of a health care
4facility from serving as a witness shall extend to directors
5and executive officers of an operator that is a corporate
6entity but not other employees of the operator such as, but not
7limited to, non-owner chaplains or social workers.
8(Source: P.A. 96-1195, eff. 7-1-11.)
9    (755 ILCS 45/4-10)  (from Ch. 110 1/2, par. 804-10)
10    Sec. 4-10. Statutory short form power of attorney for
11health care.
12    (a) The form prescribed in this Section (sometimes also
13referred to in this Act as the "statutory health care power")
14may be used to grant an agent powers with respect to the
15principal's own health care; but the statutory health care
16power is not intended to be exclusive nor to cover delegation
17of a parent's power to control the health care of a minor
18child, and no provision of this Article shall be construed to
19invalidate or bar use by the principal of any other or
20different form of power of attorney for health care.
21Nonstatutory health care powers must at a minimum contain the
22following be executed by the principal, designate the agent and
23the agent's powers, and comply with Section 4-5 of this
24Article, but they need not be witnessed or conform in any other
25respect to the statutory health care power:



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1        (1) the principal's name and address;
2        (2) language nominating an agent who is at least 18
3    years of age;
4        (3) the agent's name and address;
5        (4) an effective date or effective condition, such as
6    when a physician determines that the principal can no
7    longer make decisions;
8        (5) language specifying the agent's authority to make
9    decisions for the principal;
10        (6) specific limitations to the agent's power, if any;
11    and
12        (7) the principal's signature and date.
13    When a power of attorney in substantially the form
14prescribed in this Section is used, including the "Notice to
15the Individual Signing the Illinois Statutory Short Form Power
16of Attorney for Health Care" (or "Notice" paragraphs) at the
17beginning of the form on a separate sheet in 14-point type, it
18shall have the meaning and effect prescribed in this Act. A
19power of attorney for health care shall be deemed to be in
20substantially the same format as the statutory form if the
21explanatory language throughout the form (the language
22following the designation "NOTE:") is distinguished in some way
23from the legal paragraphs in the form, such as the use of
24boldface or other difference in typeface and font or point
25size, even if the "Notice" paragraphs at the beginning are not
26on a separate sheet of paper or are not in 14-point type, or if



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1the principal's initials do not appear in the acknowledgement
2at the end of the "Notice" paragraphs. The statutory health
3care power may be included in or combined with any other form
4of power of attorney governing property or other matters.
5    (b) The Illinois Statutory Short Form Power of Attorney for
6Health Care shall be substantially as follows:
9    No one can predict when a serious illness or accident might
10occur. When it does, you may need someone else to speak or make
11health care decisions for you. If you plan now, you can
12increase the chances that the medical treatment you get will be
13the treatment you want.
14    In Illinois, you can choose someone to be your "health care
15agent". Your agent is the person you trust to make health care
16decisions for you if you are unable or do not want to make them
17yourself. These decisions should be based on your personal
18values and wishes.
19    It is important to put your choice of agent in writing. The
20written form is often called an "advance directive". You may
21use this form or another form, as long as it meets the legal
22requirements of Illinois. There are many written and on-line
23resources to guide you and your loved ones in having a
24conversation about these issues. You may find it helpful to
25look at these resources while thinking about and discussing



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1your advance directive.
4    The selection of your agent should be considered carefully,
5as your agent will have the ultimate decision making authority
6once this document goes into effect, in most instances after
7you are no longer able to voice your own decisions. While the
8goal is for your agent to make decisions in keeping with your
9preferences and in the majority of circumstances that is what
10happens, please know that the law does allow your agent to make
11decisions in real time to direct or refuse health care
12interventions or withdraw treatment which in rare
13circumstances may override your stated preferences. Your agent
14will need to think about conversations you have had, your
15personality, and how you handled important health care issues
16in the past. Therefore, it is important to talk with your agent
17and your family about such things as:
18        (i) What is most important to you in your life?
19        (ii) How important is it to you to avoid pain and
20    suffering?
21        (iii) If you had to choose, is it more important to you
22    to live as long as possible, or to avoid prolonged
23    suffering or disability?
24        (iv) Would you rather be at home or in a hospital for
25    the last days or weeks of your life?



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1        (v) Do you have religious, spiritual, or cultural
2    beliefs that you want your agent and others to consider?
3        (vi) Do you have an existing advanced directive, such
4    as a living will, that contains your specific wishes about
5    health care that is only delaying your death? If you have
6    another advance directive, make sure to discuss with your
7    agent the directive and the treatment decisions contained
8    within that outline your preferences. Make sure that your
9    agent agrees to honor the wishes expressed in your advance
10    directive.
12    If there is ever a period of time when your doctor
13determines that you cannot make your own health care decisions,
14or if you do not want to make your own decisions, some of the
15decisions your agent could make are to:
16        (i) Talk with doctors and other health care providers
17    about your condition.
18        (ii) See medical records and approve who else can see
19    them.
20        (iii) Give permission for medical tests, medicines,
21    surgery, or other treatments.
22        (iv) Choose where you receive care and which doctors
23    and others provide it.
24        (v) Decide to accept, withdraw, or decline treatments
25    designed to keep you alive if you are near death or not



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1    likely to recover. You may choose to include guidelines
2    and/or restrictions to your agent's authority.
3        (vi) Agree or decline to donate your organs if you have
4    not already made this decision yourself. This could include
5    donation for transplant, research, and/or education. You
6    should let your agent know whether you are registered as a
7    donor in the First Person Consent registry maintained by
8    the Illinois Secretary of State.
9        (vii) Decide what to do with your remains after you
10    have died, if you have not already made plans.
11        (viii) Talk with your other loved ones to help come to
12    a decision (but your designated agent will have the final
13    say over your other loved ones).
14    Your agent is not automatically responsible for your health
15care expenses.
17    You can pick a family member, but you do not have to. Your
18agent will have the responsibility to make medical treatment
19decisions together with your doctor and other professionals,
20even if other people close to you might urge a different
21decision. The selection of your agent should be done carefully,
22as he or she will have ultimate decision-making authority for
23your treatment decisions once you are no longer able to voice
24your preferences. Choose a family member, friend, or other
25person who:



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1        (i) is at least 18 years old;
2        (ii) knows you well;
3        (iii) you trust to do what is best for you and is
4    willing to carry out your wishes, even if he or she may not
5    agree with your wishes;
6        (iv) would be comfortable talking with and questioning
7    your doctors and other health care providers;
8        (v) would not be too upset to carry out your wishes if
9    you became very sick; and
10        (vi) can be there for you when you need it and is
11    willing to accept this important role.
14    If the person who is your first choice is unable to carry
15out this role when the time comes, you can choose one or more
16successor agents. Your successor agents function as back-up
17agents to your first choice agent and may act only one at a
18time and in the order you list them.
21    If you become unable to make your own health care decisions
22and have not named an agent in writing, your doctor and other
23health care providers will ask a family member, friend, or
24guardian to make decisions for you. In Illinois, a law directs



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1which of these individuals will be consulted. In that law, each
2of these individuals is called a "surrogate".
3    There are reasons why you may want to name an agent rather
4than rely on a surrogate:
5        (i) The person or people listed by this law may not be
6    who you would want to make decisions for you.
7        (ii) Some family members or friends might not be able
8    or willing to make decisions as you would want them to.
9        (iii) Family members and friends may disagree with one
10    another about the best decisions.
11        (iv) Under some circumstances, a surrogate may not be
12    able to make the same kinds of decisions that an agent can
13    make.
16    In this situation, it is especially important to talk to
17your doctor and other health care providers and create written
18guidance about what you want or do not want, in case you are
19ever critically ill and cannot express your own wishes. You can
20complete a living will. You can also write your wishes down
21and/or discuss them with your doctor or other health care
22provider and ask him or her to write it down in your chart. You
23might also want to use written or on-line resources to guide
24you through this process.



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2    Follow these instructions after you have completed the
4        (i) Sign the form in front of a witness. See the form
5    for a list of who can and cannot witness it.
6        (ii) Ask the witness to sign it, too.
7        (iii) There is no need to have the form notarized.
8        (iv) Give a copy to your agent and to each of your
9    successor agents.
10        (v) Give another copy to your doctor.
11        (vi) Take a copy with you when you go to the hospital.
12        (vii) Show it to your family and friends and others who
13    care for you.
15    You may change your mind at any time. If you do, tell
16someone who is at least 18 years old that you have changed your
17mind, and/or destroy your document and any copies. If you wish,
18fill out a new form and make sure everyone you gave the old
19form to has a copy of the new one.
21    In the event you do not want to use the Illinois statutory
22form provided here, any document you complete must comply with
23the following minimum requirements to qualify as a valid power
24of attorney for health care:



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1        (i) it must list your name and address;
2        (ii) it must contain language nominating your agent;
3        (iii) it must list your agent's name and address;
4        (iv) it must contain an effective date or effective
5    condition such as when a physician determines that you can
6    no longer make decisions for yourself;
7        (v) it must describe your agent's authority to make
8    decisions for you;
9        (vi) it must list specific limitations to your agent's
10    power, if any; and
11        (vii) it must contain your signature and date.
12    If you have questions about the use of any form, you may
13want to consult your doctor, other health care provider, and/or
14an attorney. While Illinois law does not require the use of an
15attorney to complete a power of attorney, individuals may
16consult an attorney to address any questions or to seek
17assistance in completing the document.

20FOR HEALTH CARE. (You must sign this form and a witness must
21also sign it before it is valid)
22My name (Print your full name):..............................
23My address:..................................................



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2(an agent is your personal representative under state and
3federal law, but your agent may not be your physician or health
4care provider):
5(Agent name).................................................
6(Agent address)..............................................
7(Agent phone number).........................................
9        (i) Deciding to accept, withdraw or decline treatment
10    for any physical or mental condition of mine, including
11    life-and-death decisions.
12        (ii) Agreeing to admit me to or discharge me from any
13    hospital, home, or other institution, including a mental
14    health facility.
15        (iii) Having complete access to my medical and mental
16    health records, and sharing them with others as needed,
17    including after I die.
18        (iv) Carrying out the plans I have already made, or, if
19    I have not done so, making decisions about my body or
20    remains, including organ, tissue or body donation,
21    autopsy, cremation, and burial.
22I AUTHORIZE MY AGENT TO (please check any one box):
23    .... Make decisions for me only when I cannot make them for



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1    myself. The physician(s) taking care of me will determine
2    when I lack this ability.
3    .... Make decisions for me starting now and continuing
4    after I am no longer able to make them for myself. While I
5    am still able to make my own decisions, I can still do so
6    if I want to.
8WISHES (optional):
9    The subject of life-sustaining treatment is of particular
10importance. Life-sustaining treatments may include tube
11feedings or fluids through a tube, breathing machines, and CPR.
12Some general statements concerning the withholding or removal
13of life-sustaining treatment are described below. This can
14serve as a guide for your agent when making decisions for you.
15Ask your physician or health care provider if you have any
16questions about these statements.
17    .... If my agent thinks the burdens of the treatments will
18    probably be greater than any benefits, I do not want
19    treatments to prolong my life. I want my agent to consider
20    the relief of suffering, the expense involved, and the
21    quality as well as the possible extension of my life in
22    making decisions concerning life-sustaining treatment.
23    Treatments I would not want if I were to reach this point
24    include but are not limited to tube feedings or fluids
25    through a tube, breathing machines, and CPR.



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1    .... In the event that I am unconscious and my attending
2    physician believes that I will not wake up or recover my
3    ability to think, communicate with my family and friends,
4    and experience my surroundings, I do not want treatments to
5    prolong my life.
6    .... I want my life to be prolonged to the greatest extent
7    possible, in accordance with reasonable medical standards,
8    no matter how sick I am, how much I am suffering, the cost
9    of the procedures, or how unlikely my chances for recovery
10    are.
11    .... I prefer not to select any of the above statements.
15My signature:................................................
16Today's date:................................................
19    I am at least 18 years old. I saw the principal sign this
20document of ..... (fill in number) pages, or the principal told
21me that the signature or mark on the principal signature line
22is his or hers. I am not the agent or successor agent(s) named
23in this document. I am not related to the principal, the agent,



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1or the successor agent(s) by blood, marriage, or adoption. I am
2not the principal's physician, mental health service provider,
3or a relative of one of those individuals. I am not an owner or
4operator (or the relative of an owner or operator) of the
5health care facility where the principal is a patient or
7Witness printed name:........................................
8Witness address:.............................................
9Witness signature:...........................................
10Today's date:................................................
12    If the agent I selected is unable or does not want to make
13health care decisions for me, then I request the person(s) I
14name below to be my successor health care agent(s). Only one
15person at a time can serve as my agent (add another page if you
16want to add more successor agent names):
18(Successor agent #1 name, address and phone number)
20(Successor agent #2 name, address and phone number)
22    You may, but are not required to, request your agent and
23successor agents to provide sample signatures below. If you
24include sample signatures in this power of attorney, you must



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1complete the certification opposite the signatures of the
3I certify that the following signatures of my agent and
4successor agents are correct:
5.................. (agent)    .................. (principal) 
6.................. (agent)    .................. (principal) 
7.................. (agent)    .................. (principal) 

10    PLEASE READ THIS NOTICE CAREFULLY. The form that you will
11be signing is a legal document. It is governed by the Illinois
12Power of Attorney Act. If there is anything about this form
13that you do not understand, you should ask a lawyer to explain
14it to you.
15    The purpose of this Power of Attorney is to give your
16designated "agent" broad powers to make health care decisions
17for you, including the power to require, consent to, or
18withdraw treatment for any physical or mental condition, and to
19admit you or discharge you from any hospital, home, or other
20institution. You may name successor agents under this form, but
21you may not name co-agents.
22    This form does not impose a duty upon your agent to make
23such health care decisions, so it is important that you select



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1an agent who will agree to do this for you and who will make
2those decisions as you would wish. It is also important to
3select an agent whom you trust, since you are giving that agent
4control over your medical decision-making, including
5end-of-life decisions. Any agent who does act for you has a
6duty to act in good faith for your benefit and to use due care,
7competence, and diligence. He or she must also act in
8accordance with the law and with the statements in this form.
9Your agent must keep a record of all significant actions taken
10as your agent.
11    Unless you specifically limit the period of time that this
12Power of Attorney will be in effect, your agent may exercise
13the powers given to him or her throughout your lifetime, even
14after you become disabled. A court, however, can take away the
15powers of your agent if it finds that the agent is not acting
16properly. You may also revoke this Power of Attorney if you
18    The Powers you give your agent, your right to revoke those
19powers, and the penalties for violating the law are explained
20more fully in Sections 4-5, 4-6, and 4-10(c) of the Illinois
21Power of Attorney Act. This form is a part of that law. The
22"NOTE" paragraphs throughout this form are instructions.
23    You are not required to sign this Power of Attorney, but it
24will not take effect without your signature. You should not
25sign it if you do not understand everything in it, and what
26your agent will be able to do if you do sign it.



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1    Please put your initials on the following line indicating
2that you have read this Notice:
(Principal's initials)"


7    1. I, ..................................................,
8(insert name and address of principal) hereby revoke all prior
9powers of attorney for health care executed by me and appoint:
11(insert name and address of agent)
12(NOTE: You may not name co-agents using this form.)
13as my attorney-in-fact (my "agent") to act for me and in my
14name (in any way I could act in person) to make any and all
15decisions for me concerning my personal care, medical
16treatment, hospitalization and health care and to require,
17withhold or withdraw any type of medical treatment or
18procedure, even though my death may ensue.
19    A. My agent shall have the same access to my medical
20records that I have, including the right to disclose the
21contents to others.
22    B. Effective upon my death, my agent has the full power to
23make an anatomical gift of the following:



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1(NOTE: Initial one. In the event none of the options are
2initialed, then it shall be concluded that you do not wish to
3grant your agent any such authority.)
4        .... Any organs, tissues, or eyes suitable for
5    transplantation or used for research or education.
6        .... Specific organs:................................
7        .... I do not grant my agent authority to make any
8    anatomical gifts.
9    C. My agent shall also have full power to authorize an
10autopsy and direct the disposition of my remains. I intend for
11this power of attorney to be in substantial compliance with
12Section 10 of the Disposition of Remains Act. All decisions
13made by my agent with respect to the disposition of my remains,
14including cremation, shall be binding. I hereby direct any
15cemetery organization, business operating a crematory or
16columbarium or both, funeral director or embalmer, or funeral
17establishment who receives a copy of this document to act under
19    D. I intend for the person named as my agent to be treated
20as I would be with respect to my rights regarding the use and
21disclosure of my individually identifiable health information
22or other medical records, including records or communications
23governed by the Mental Health and Developmental Disabilities
24Confidentiality Act. This release authority applies to any
25information governed by the Health Insurance Portability and
26Accountability Act of 1996 ("HIPAA") and regulations



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1thereunder. I intend for the person named as my agent to serve
2as my "personal representative" as that term is defined under
3HIPAA and regulations thereunder.
4    (i) The person named as my agent shall have the power to
5authorize the release of information governed by HIPAA to third
7    (ii) I authorize any physician, health care professional,
8dentist, health plan, hospital, clinic, laboratory, pharmacy
9or other covered health care provider, any insurance company
10and the Medical Informational Bureau, Inc., or any other health
11care clearinghouse that has provided treatment or services to
12me, or that has paid for or is seeking payment for me for such
13services to give, disclose, and release to the person named as
14my agent, without restriction, all of my individually
15identifiable health information and medical records, regarding
16any past, present, or future medical or mental health
17condition, including all information relating to the diagnosis
18and treatment of HIV/AIDS, sexually transmitted diseases, drug
19or alcohol abuse, and mental illness (including records or
20communications governed by the Mental Health and Developmental
21Disabilities Confidentiality Act).
22    (iii) The authority given to the person named as my agent
23shall supersede any prior agreement that I may have with my
24health care providers to restrict access to, or disclosure of,
25my individually identifiable health information. The authority
26given to the person named as my agent has no expiration date



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1and shall expire only in the event that I revoke the authority
2in writing and deliver it to my health care provider.
3(NOTE: The above grant of power is intended to be as broad as
4possible so that your agent will have the authority to make any
5decision you could make to obtain or terminate any type of
6health care, including withdrawal of food and water and other
7life-sustaining measures, if your agent believes such action
8would be consistent with your intent and desires. If you wish
9to limit the scope of your agent's powers or prescribe special
10rules or limit the power to make an anatomical gift, authorize
11autopsy or dispose of remains, you may do so in the following
13    2. The powers granted above shall not include the following
14powers or shall be subject to the following rules or
16(NOTE: Here you may include any specific limitations you deem
17appropriate, such as: your own definition of when
18life-sustaining measures should be withheld; a direction to
19continue food and fluids or life-sustaining treatment in all
20events; or instructions to refuse any specific types of
21treatment that are inconsistent with your religious beliefs or
22unacceptable to you for any other reason, such as blood
23transfusion, electro-convulsive therapy, amputation,
24psychosurgery, voluntary admission to a mental institution,



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5(NOTE: The subject of life-sustaining treatment is of
6particular importance. For your convenience in dealing with
7that subject, some general statements concerning the
8withholding or removal of life-sustaining treatment are set
9forth below. If you agree with one of these statements, you may
10initial that statement; but do not initial more than one. These
11statements serve as guidance for your agent, who shall give
12careful consideration to the statement you initial when
13engaging in health care decision-making on your behalf.)
14    I do not want my life to be prolonged nor do I want
15life-sustaining treatment to be provided or continued if my
16agent believes the burdens of the treatment outweigh the
17expected benefits. I want my agent to consider the relief of
18suffering, the expense involved and the quality as well as the
19possible extension of my life in making decisions concerning
20life-sustaining treatment.
Initialed ...........................
22    I want my life to be prolonged and I want life-sustaining
23treatment to be provided or continued, unless I am, in the
24opinion of my attending physician, in accordance with
25reasonable medical standards at the time of reference, in a
26state of "permanent unconsciousness" or suffer from an



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1"incurable or irreversible condition" or "terminal condition",
2as those terms are defined in Section 4-4 of the Illinois Power
3of Attorney Act. If and when I am in any one of these states or
4conditions, I want life-sustaining treatment to be withheld or
Initialed ...........................
7    I want my life to be prolonged to the greatest extent
8possible in accordance with reasonable medical standards
9without regard to my condition, the chances I have for recovery
10or the cost of the procedures.
Initialed ...........................
12(NOTE: This power of attorney may be amended or revoked by you
13in the manner provided in Section 4-6 of the Illinois Power of
14Attorney Act.)
15    3.   This power of attorney shall become effective on
18(NOTE: Insert a future date or event during your lifetime, such
19as a court determination of your disability or a written
20determination by your physician that you are incapacitated,
21when you want this power to first take effect.)
22(NOTE: If you do not amend or revoke this power, or if you do
23not specify a specific ending date in paragraph 4, it will
24remain in effect until your death; except that your agent will
25still have the authority to donate your organs, authorize an
26autopsy, and dispose of your remains after your death, if you



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1grant that authority to your agent.)
2    4.   This power of attorney shall terminate on ..........
4(NOTE: Insert a future date or event, such as a court
5determination that you are not under a legal disability or a
6written determination by your physician that you are not
7incapacitated, if you want this power to terminate prior to
8your death.)
9(NOTE: You cannot use this form to name co-agents. If you wish
10to name successor agents, insert the names and addresses of the
11successors in paragraph 5.)
12    5. If any agent named by me shall die, become incompetent,
13resign, refuse to accept the office of agent or be unavailable,
14I name the following (each to act alone and successively, in
15the order named) as successors to such agent:
18For purposes of this paragraph 5, a person shall be considered
19to be incompetent if and while the person is a minor, or an
20adjudicated incompetent or disabled person, or the person is
21unable to give prompt and intelligent consideration to health
22care matters, as certified by a licensed physician.
23(NOTE: If you wish to, you may name your agent as guardian of
24your person if a court decides that one should be appointed. To
25do this, retain paragraph 6, and the court will appoint your
26agent if the court finds that this appointment will serve your



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1best interests and welfare. Strike out paragraph 6 if you do
2not want your agent to act as guardian.)
3    6. If a guardian of my person is to be appointed, I
4nominate the agent acting under this power of attorney as such
5guardian, to serve without bond or security.
6    7. I am fully informed as to all the contents of this form
7and understand the full import of this grant of powers to my
9Dated: .......... 
Signed ..............................
(principal's signature or mark)
12    The principal has had an opportunity to review the above
13form and has signed the form or acknowledged his or her
14signature or mark on the form in my presence. The undersigned
15witness certifies that the witness is not: (a) the attending
16physician or mental health service provider or a relative of
17the physician or provider; (b) an owner, operator, or relative
18of an owner or operator of a health care facility in which the
19principal is a patient or resident; (c) a parent, sibling,
20descendant, or any spouse of such parent, sibling, or
21descendant of either the principal or any agent or successor
22agent under the foregoing power of attorney, whether such
23relationship is by blood, marriage, or adoption; or (d) an
24agent or successor agent under the foregoing power of attorney.



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(Witness Signature)
(Print Witness Name)
(Street Address)
(City, State, ZIP)
8(NOTE: You may, but are not required to, request your agent and
9successor agents to provide specimen signatures below. If you
10include specimen signatures in this power of attorney, you must
11complete the certification opposite the signatures of the
13Specimen signatures of    I certify that the signatures of my
14agent (and successors).   agent (and successors) are correct.
15.......................   ...................................
16       (agent)                      (principal)
17.......................   ...................................
18   (successor agent)                (principal)
19.......................   ...................................
20   (successor agent)                (principal)"
21    (NOTE: The name, address, and phone number of the person
22preparing this form or who assisted the principal in completing
23this form is optional.)
(name of preparer)



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6    (c) The statutory short form power of attorney for health
7care (the "statutory health care power") authorizes the agent
8to make any and all health care decisions on behalf of the
9principal which the principal could make if present and under
10no disability, subject to any limitations on the granted powers
11that appear on the face of the form, to be exercised in such
12manner as the agent deems consistent with the intent and
13desires of the principal. The agent will be under no duty to
14exercise granted powers or to assume control of or
15responsibility for the principal's health care; but when
16granted powers are exercised, the agent will be required to use
17due care to act for the benefit of the principal in accordance
18with the terms of the statutory health care power and will be
19liable for negligent exercise. The agent may act in person or
20through others reasonably employed by the agent for that
21purpose but may not delegate authority to make health care
22decisions. The agent may sign and deliver all instruments,
23negotiate and enter into all agreements and do all other acts
24reasonably necessary to implement the exercise of the powers
25granted to the agent. Without limiting the generality of the
26foregoing, the statutory health care power shall include the



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1following powers, subject to any limitations appearing on the
2face of the form:
3        (1) The agent is authorized to give consent to and
4    authorize or refuse, or to withhold or withdraw consent to,
5    any and all types of medical care, treatment or procedures
6    relating to the physical or mental health of the principal,
7    including any medication program, surgical procedures,
8    life-sustaining treatment or provision of food and fluids
9    for the principal.
10        (2) The agent is authorized to admit the principal to
11    or discharge the principal from any and all types of
12    hospitals, institutions, homes, residential or nursing
13    facilities, treatment centers and other health care
14    institutions providing personal care or treatment for any
15    type of physical or mental condition. The agent shall have
16    the same right to visit the principal in the hospital or
17    other institution as is granted to a spouse or adult child
18    of the principal, any rule of the institution to the
19    contrary notwithstanding.
20        (3) The agent is authorized to contract for any and all
21    types of health care services and facilities in the name of
22    and on behalf of the principal and to bind the principal to
23    pay for all such services and facilities, and to have and
24    exercise those powers over the principal's property as are
25    authorized under the statutory property power, to the
26    extent the agent deems necessary to pay health care costs;



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1    and the agent shall not be personally liable for any
2    services or care contracted for on behalf of the principal.
3        (4) At the principal's expense and subject to
4    reasonable rules of the health care provider to prevent
5    disruption of the principal's health care, the agent shall
6    have the same right the principal has to examine and copy
7    and consent to disclosure of all the principal's medical
8    records that the agent deems relevant to the exercise of
9    the agent's powers, whether the records relate to mental
10    health or any other medical condition and whether they are
11    in the possession of or maintained by any physician,
12    psychiatrist, psychologist, therapist, hospital, nursing
13    home or other health care provider.
14        (5) The agent is authorized: to direct that an autopsy
15    be made pursuant to Section 2 of "An Act in relation to
16    autopsy of dead bodies", approved August 13, 1965,
17    including all amendments; to make a disposition of any part
18    or all of the principal's body pursuant to the Illinois
19    Anatomical Gift Act, as now or hereafter amended; and to
20    direct the disposition of the principal's remains.
21(Source: P.A. 96-1195, eff. 7-1-11; 97-148, eff. 7-14-11.)