(755 ILCS 45/4‑10)
(from Ch. 110 1/2, par. 804‑10)
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
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transplantation or used for research or education.
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....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.):
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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(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 |
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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.
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(2) The agent is authorized to admit the principal to
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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.
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(3) The agent is authorized to contract for any and
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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.
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(4) At the principal's expense and subject to
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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.
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(5) The agent is authorized: to direct that an
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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.
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(Source: P.A. 93‑794, eff. 7‑22‑04.)
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