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Public Act 097-0148 | ||||
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AN ACT concerning civil law.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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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)
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(Text of Section before amendment by P.A. 96-1195 )
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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 ...........................
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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.)
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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.
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