Full Text of SB1877 97th General Assembly
SB1877eng 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning civil law.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Power of Attorney Act is amended by | 5 | | changing Section 4-10 as follows:
| 6 | | (755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10)
| 7 | | (Text of Section before amendment by P.A. 96-1195 )
| 8 | | Sec. 4-10. Statutory short form power of attorney for | 9 | | health care.
| 10 | | (a) The following form (sometimes also referred to in this | 11 | | Act as the
"statutory health care power") may be used to grant | 12 | | an agent powers with
respect to the principal's own health | 13 | | care; but the statutory health care
power is not intended to be | 14 | | exclusive nor to cover delegation of a parent's
power to | 15 | | control the health care of a minor child, and no provision of | 16 | | this
Article shall be construed to invalidate or bar use by the | 17 | | principal of any
other or
different form of power of attorney | 18 | | for health care. Nonstatutory health
care powers must be
| 19 | | executed by the principal, designate the agent and the agent's | 20 | | powers, and
comply with Section 4-5 of this Article, but they | 21 | | need not be witnessed or
conform in any other respect to the | 22 | | statutory health care power. When a
power of attorney in | 23 | | substantially the
following form is used, including the |
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| 1 | | "notice" paragraph at the beginning
in capital letters, it | 2 | | shall have the meaning and effect prescribed in this
Act. The | 3 | | statutory health care power may be included in or
combined with | 4 | | any
other form of power of attorney governing property or other | 5 | | matters.
| 6 | | "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH | 7 | | CARE
| 8 | | (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE | 9 | | THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE | 10 | | HEALTH CARE DECISIONS FOR YOU,
INCLUDING POWER TO REQUIRE, | 11 | | CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL
CARE OR MEDICAL | 12 | | TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT
YOU | 13 | | TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER | 14 | | INSTITUTION. THIS
FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO | 15 | | EXERCISE GRANTED POWERS; BUT
WHEN POWERS ARE EXERCISED, YOUR | 16 | | AGENT WILL HAVE TO USE
DUE CARE TO ACT FOR
YOUR BENEFIT AND IN | 17 | | ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF
RECEIPTS, | 18 | | DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT
| 19 | | CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS | 20 | | NOT ACTING PROPERLY. YOU MAY
NAME SUCCESSOR AGENTS UNDER THIS | 21 | | FORM
BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE | 22 | | NAMED. UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER
IN | 23 | | THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A | 24 | | COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY | 25 | | EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN | 26 | | AFTER YOU BECOME DISABLED. THE POWERS YOU
GIVE YOUR AGENT, YOUR |
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| 1 | | RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR
VIOLATING | 2 | | THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND
| 3 | | 4-10(b) OF THE ILLINOIS
"POWERS OF ATTORNEY FOR HEALTH CARE | 4 | | LAW"
OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM). | 5 | | THAT LAW
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF | 6 | | POWER OF ATTORNEY YOU
MAY DESIRE. IF THERE IS ANYTHING ABOUT | 7 | | THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER | 8 | | TO EXPLAIN IT TO YOU.)
| 9 | | POWER OF ATTORNEY made this .......................day of
| 10 | | ................................
| 11 | | (month) (year)
| 12 | | 1. I, ..................................................,
| 13 | | (insert name and address of principal)
| 14 | | hereby appoint:
| 15 | | ............................................................
| 16 | | (insert name and address of agent)
| 17 | | as my attorney-in-fact (my "agent") to act for me and in my | 18 | | name (in any
way I could act in person) to make any and all | 19 | | decisions for me concerning
my personal care, medical | 20 | | treatment, hospitalization and health care and to
require, | 21 | | withhold or withdraw any type of medical treatment or | 22 | | procedure,
even though my death may ensue. My agent shall have | 23 | | the same access to my
medical records that I have, including | 24 | | the right to disclose the contents
to others. My agent shall | 25 | | also have full power to
authorize an autopsy and direct the | 26 | | disposition of my remains.
Effective upon my death, my agent |
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| 1 | | has the full power to make an anatomical
gift of the following | 2 | | (initial one):
| 3 | | ....Any organs, tissues, or eyes suitable for | 4 | | transplantation or used for
research or education.
| 5 | | ....Specific organs: .................................
| 6 | | (THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS | 7 | | POSSIBLE SO THAT
YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY | 8 | | DECISION YOU COULD MAKE TO
OBTAIN OR TERMINATE ANY TYPE OF | 9 | | HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD
AND WATER AND OTHER | 10 | | LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH
ACTION | 11 | | WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU WISH | 12 | | TO
LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE SPECIAL | 13 | | RULES OR LIMIT
THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE | 14 | | AUTOPSY OR DISPOSE OF
REMAINS, YOU MAY DO SO IN THE FOLLOWING | 15 | | PARAGRAPHS.)
| 16 | | 2. The powers granted above shall not include the following | 17 | | powers or
shall be subject to the following rules or | 18 | | limitations (here you may include
any specific limitations you | 19 | | deem appropriate, such as: your own
definition of when | 20 | | life-sustaining measures should be withheld; a direction
to | 21 | | continue food and fluids or life-sustaining treatment in
all | 22 | | events; or instructions to refuse
any specific types of | 23 | | treatment that are inconsistent with your religious
beliefs or | 24 | | unacceptable to you for any other reason, such as blood
| 25 | | transfusion, electro-convulsive therapy, amputation, | 26 | | psychosurgery,
voluntary admission to a mental institution, |
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| 1 | | etc.):
| 2 | | .............................................................
| 3 | | .............................................................
| 4 | | .............................................................
| 5 | | .............................................................
| 6 | | .............................................................
| 7 | | (THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR | 8 | | IMPORTANCE. FOR
YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, | 9 | | SOME GENERAL STATEMENTS
CONCERNING THE WITHHOLDING OR REMOVAL | 10 | | OF LIFE-SUSTAINING TREATMENT ARE SET
FORTH BELOW. IF YOU AGREE | 11 | | WITH ONE OF THESE STATEMENTS, YOU MAY
INITIAL THAT STATEMENT; | 12 | | BUT DO NOT INITIAL MORE THAN ONE):
| 13 | | I do not want my life to be prolonged nor do I want | 14 | | life-sustaining
treatment to be provided or continued if my | 15 | | agent believes the burdens of
the treatment outweigh the | 16 | | expected benefits. I want my agent to consider
the relief of | 17 | | suffering, the expense involved and the quality as well as
the | 18 | | possible extension of my life in making decisions concerning
| 19 | | life-sustaining treatment.
| 20 | | Initialed...........................
| 21 | | I want my life to be prolonged and I want life-sustaining | 22 | | treatment to be
provided or continued unless I am in a coma | 23 | | which my attending physician
believes to be irreversible, in | 24 | | accordance with reasonable medical
standards at the time of | 25 | | reference. If and when I have suffered
irreversible coma, I | 26 | | want life-sustaining treatment to be withheld or
discontinued.
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| 1 | | Initialed...........................
| 2 | | I want my life to be prolonged to the greatest extent | 3 | | possible without
regard to my condition, the chances I have for | 4 | | recovery or the cost of the
procedures.
| 5 | | Initialed...........................
| 6 | | (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE | 7 | | MANNER
PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF | 8 | | ATTORNEY FOR HEALTH CARE
LAW" (SEE THE BACK OF THIS FORM). | 9 | | ABSENT AMENDMENT OR
REVOCATION, THE AUTHORITY GRANTED IN THIS
| 10 | | POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER | 11 | | IS SIGNED
AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF | 12 | | ANATOMICAL GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS | 13 | | AUTHORIZED, UNLESS A LIMITATION ON THE
BEGINNING DATE OR | 14 | | DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR
BOTH OF | 15 | | THE FOLLOWING:)
| 16 | | 3. ( ) This power of attorney shall become effective on
| 17 | | .............................................................
| 18 | | .............................................................
| 19 | | (insert a future date or event during your lifetime, such as | 20 | | court
determination of your disability, when you want this | 21 | | power to first take
effect)
| 22 | | 4. ( ) This power of attorney shall terminate on
.......
| 23 | | .............................................................
| 24 | | (insert a future date or event, such as court determination of | 25 | | your
disability, when you want this power to terminate prior to | 26 | | your death)
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| 1 | | (IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND | 2 | | ADDRESSES OF
SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)
| 3 | | 5. If any agent named by me shall die, become incompetent, | 4 | | resign,
refuse to accept the office of agent or be unavailable, | 5 | | I name
the following (each to act alone
and successively, in | 6 | | the order named) as successors to such agent:
| 7 | | .............................................................
| 8 | | .............................................................
| 9 | | For purposes of this paragraph 5, a person shall be considered | 10 | | to be
incompetent if and while the person is a minor or an | 11 | | adjudicated
incompetent or disabled person or the person is | 12 | | unable to give prompt and
intelligent consideration to health | 13 | | care matters, as certified by a licensed physician.
(IF YOU | 14 | | WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON,
IN THE | 15 | | EVENT A COURT DECIDES
THAT ONE SHOULD BE APPOINTED, YOU MAY, | 16 | | BUT ARE NOT REQUIRED TO, DO SO BY
RETAINING THE FOLLOWING
| 17 | | PARAGRAPH. THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS | 18 | | THAT SUCH
APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND | 19 | | WELFARE. STRIKE OUT
PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT | 20 | | TO ACT AS GUARDIAN.)
| 21 | | 6. If a guardian of my person is to be appointed, I | 22 | | nominate the agent
acting under this power of attorney as such
| 23 | | guardian, to serve without bond or security.
| 24 | | 7. I am fully informed as to all the contents of this form | 25 | | and
understand the full import of this grant of powers to my | 26 | | agent.
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| 1 | | Signed..............................
| 2 | | (principal)
| 3 | | The principal has had an opportunity to read the above form | 4 | | and has
signed the form or acknowledged his or her signature or | 5 | | mark on the form in my presence.
| 6 | | .......................... Residing at......................
| 7 | | (witness)
| 8 | | (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND | 9 | | SUCCESSOR AGENTS
TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU | 10 | | INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST | 11 | | COMPLETE THE CERTIFICATION OPPOSITE THE
SIGNATURES OF THE | 12 | | AGENTS.)
| 13 | | Specimen signatures of I certify that the signatures of my
| 14 | | agent (and successors). agent (and successors) are correct.
| 15 | | ....................... ...................................
| 16 | | (agent) (principal)
| 17 | | ....................... ...................................
| 18 | | (successor agent) (principal)
| 19 | | ....................... ...................................
| 20 | | (successor agent) (principal)"
| 21 | | (b) The statutory short form power of attorney for health | 22 | | care (the
"statutory health care power") authorizes the agent | 23 | | to make any and all
health care decisions on behalf of the | 24 | | principal which the principal could
make if present and under | 25 | | no disability, subject to any limitations on the
granted powers | 26 | | that appear on the face of the form, to be exercised in such
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| 1 | | manner as the agent deems consistent with the intent and | 2 | | desires of the
principal. The agent will be under no duty to | 3 | | exercise granted powers or
to assume control of or | 4 | | responsibility for the principal's health care;
but when | 5 | | granted powers are exercised, the agent will be required to use
| 6 | | due care to act for the benefit of the principal in accordance | 7 | | with the
terms of the statutory health care power and will be | 8 | | liable
for negligent exercise. The agent may act in person or | 9 | | through others
reasonably employed by the agent for that | 10 | | purpose
but may not delegate authority to make health care | 11 | | decisions. The agent
may sign and deliver all instruments, | 12 | | negotiate and enter into all
agreements and do all other acts | 13 | | reasonably necessary to implement the
exercise of the powers | 14 | | granted to the agent. Without limiting the
generality of the | 15 | | foregoing, the statutory health care power shall include
the | 16 | | following powers, subject to any limitations appearing on the | 17 | | face of the form:
| 18 | | (1) The agent is authorized to give consent to and | 19 | | authorize or refuse,
or to withhold or withdraw consent to, | 20 | | any and all types of medical care,
treatment or procedures | 21 | | relating to the physical or mental health of the
principal, | 22 | | including any medication program, surgical procedures,
| 23 | | life-sustaining treatment or provision of food and fluids | 24 | | for the principal.
| 25 | | (2) The agent is authorized to admit the principal to | 26 | | or discharge the
principal from any and all types of |
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| 1 | | hospitals, institutions, homes,
residential or nursing | 2 | | facilities, treatment centers and other health care
| 3 | | institutions providing personal care or treatment for any | 4 | | type of physical
or mental condition. The agent shall have | 5 | | the same right to visit the
principal in the hospital or | 6 | | other institution as is granted to a spouse or
adult child | 7 | | of the principal, any rule of the institution to the | 8 | | contrary
notwithstanding.
| 9 | | (3) The agent is authorized to contract for any and all | 10 | | types of health
care services and facilities in the name of | 11 | | and on behalf of the principal
and to bind the principal to | 12 | | pay for all such services and facilities,
and to have and | 13 | | exercise those powers over the principal's property as are
| 14 | | authorized under the statutory property power, to the | 15 | | extent the agent
deems necessary to pay health care costs; | 16 | | and
the agent shall not be personally liable for any | 17 | | services or care contracted
for on behalf of the principal.
| 18 | | (4) At the principal's expense and subject to | 19 | | reasonable rules of the
health care provider to prevent | 20 | | disruption of the principal's health care,
the agent shall | 21 | | have the same right the principal has to examine and copy
| 22 | | and consent to disclosure of all the principal's medical | 23 | | records that the agent deems
relevant to the exercise of | 24 | | the agent's powers, whether the records
relate to mental | 25 | | health or any other medical condition and whether they are | 26 | | in
the possession of or maintained by any physician, |
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| 1 | | psychiatrist,
psychologist, therapist, hospital, nursing | 2 | | home or other health care
provider.
| 3 | | (5) The agent is authorized: to direct that an autopsy | 4 | | be made pursuant
to Section 2 of "An Act in relation to | 5 | | autopsy of dead bodies", approved
August 13, 1965, | 6 | | including all amendments;
to make a disposition of any
part | 7 | | or all of the principal's body pursuant to the Illinois | 8 | | Anatomical Gift
Act, as now or hereafter amended; and to | 9 | | direct the disposition of the
principal's remains.
| 10 | | (Source: P.A. 93-794, eff. 7-22-04.)
| 11 | | (Text of Section after amendment by P.A. 96-1195 )
| 12 | | Sec. 4-10. Statutory short form power of attorney for | 13 | | health care.
| 14 | | (a) The form prescribed in this Section (sometimes also | 15 | | referred to in this Act as the
"statutory health care power") | 16 | | may be used to grant an agent powers with
respect to the | 17 | | principal's own health care; but the statutory health care
| 18 | | power is not intended to be exclusive nor to cover delegation | 19 | | of a parent's
power to control the health care of a minor | 20 | | child, and no provision of this
Article shall be construed to | 21 | | invalidate or bar use by the principal of any
other or
| 22 | | different form of power of attorney for health care. | 23 | | Nonstatutory health
care powers must be
executed by the | 24 | | principal, designate the agent and the agent's powers, and
| 25 | | comply with Section 4-5 of this Article, but they need not be |
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| 1 | | witnessed or
conform in any other respect to the statutory | 2 | | health care power. When a
power of attorney in substantially | 3 | | the
form prescribed in this Section is used, including the | 4 | | "Notice to the Individual Signing the Illinois Statutory Short | 5 | | Form Power of Attorney for Health Care" (or "Notice" | 6 | | paragraphs) at the beginning of the form on a separate sheet in | 7 | | 14-point type, it shall have the meaning and effect prescribed | 8 | | in this
Act. A power of attorney for health care shall be | 9 | | deemed to be in substantially the same format as the statutory | 10 | | form if the explanatory language throughout the form (the | 11 | | language following the designation "NOTE:") is distinguished | 12 | | in some way from the legal paragraphs in the form, such as the | 13 | | use of boldface or other difference in typeface and font or | 14 | | point size, even if the "Notice" paragraphs at the beginning | 15 | | are not on a separate sheet of paper or are not in 14-point | 16 | | type, or if the principal's initials do not appear in the | 17 | | acknowledgement at the end of the "Notice" paragraphs. The | 18 | | statutory health care power may be included in or
combined with | 19 | | any
other form of power of attorney governing property or other | 20 | | matters.
| 21 | | (b) The Illinois Statutory Short Form Power of Attorney for | 22 | | Health Care shall be substantially as follows: | 23 | | "NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS | 24 | | STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE |
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| 1 | | PLEASE READ THIS NOTICE CAREFULLY. The form that you will | 2 | | be signing is a legal document. It is governed by the Illinois | 3 | | Power of Attorney Act. If there is anything about this form | 4 | | that you do not understand, you should ask a lawyer to explain | 5 | | it to you. | 6 | | The purpose of this Power of Attorney is to give your | 7 | | designated "agent" broad powers to make health care decisions | 8 | | for you, including the power to require, consent to, or | 9 | | withdraw treatment for any physical or mental condition, and to | 10 | | admit you or discharge you from any hospital, home, or other | 11 | | institution. You may name successor agents under this form, but | 12 | | you may not name co-agents. | 13 | | This form does not impose a duty upon your agent to make | 14 | | such health care decisions, so it is important that you select | 15 | | an agent who will agree to do this for you and who will make | 16 | | those decisions as you would wish. It is also important to | 17 | | select an agent whom you trust, since you are giving that agent | 18 | | control over your medical decision-making, including | 19 | | end-of-life decisions. Any agent who does act for you has a | 20 | | duty to act in good faith for your benefit and to use due care, | 21 | | competence, and diligence. He or she must also act in | 22 | | accordance with the law and with the statements in this form. | 23 | | Your agent must keep a record of all significant actions taken | 24 | | as your agent. | 25 | | Unless you specifically limit the period of time that this | 26 | | Power of Attorney will be in effect, your agent may exercise |
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| 1 | | the powers given to him or her throughout your lifetime, even | 2 | | after you become disabled. A court, however, can take away the | 3 | | powers of your agent if it finds that the agent is not acting | 4 | | properly. You may also revoke this Power of Attorney if you | 5 | | wish. | 6 | | The Powers you give your agent, your right to revoke those | 7 | | powers, and the penalties for violating the law are explained | 8 | | more fully in Sections 4-5, 4-6, and 4-10(c) 4-10(b) of the | 9 | | Illinois Power of Attorney Act. This form is a part of that | 10 | | law. The "NOTE" paragraphs throughout this form are | 11 | | instructions. | 12 | | You are not required to sign this Power of Attorney, but it | 13 | | will not take effect without your signature. You should not | 14 | | sign it if you do not understand everything in it, and what | 15 | | your agent will be able to do if you do sign it. | 16 | | Please put your initials on the following line indicating | 17 | | that you have read this Notice: | 18 | | ......................
| 19 | | (Principal's initials)"
| 20 | | "ILLINOIS STATUTORY SHORT FORM | 21 | | POWER OF ATTORNEY FOR HEALTH CARE
| 22 | | 1. I, ..................................................,
| 23 | | (insert name and address of principal)
hereby revoke all prior |
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| 1 | | powers of attorney for health care executed by me and appoint:
| 2 | | ............................................................
| 3 | | (insert name and address of agent)
| 4 | | (NOTE: You may not name co-agents using this form.) | 5 | | as my attorney-in-fact (my "agent") to act for me and in my | 6 | | name (in any
way I could act in person) to make any and all | 7 | | decisions for me concerning
my personal care, medical | 8 | | treatment, hospitalization and health care and to
require, | 9 | | withhold or withdraw any type of medical treatment or | 10 | | procedure,
even though my death may ensue. | 11 | | A. My agent shall have the same access to my
medical | 12 | | records that I have, including the right to disclose the | 13 | | contents
to others. | 14 | | B.
Effective upon my death, my agent has the full power to | 15 | | make an anatomical
gift of the following: | 16 | | (NOTE: Initial one. In the event none of the options are | 17 | | initialed, then it shall be concluded that you do not wish to | 18 | | grant your agent any such authority.)
| 19 | | .... Any organs, tissues, or eyes suitable for | 20 | | transplantation or used for
research or education.
| 21 | | .... Specific organs: ................................
| 22 | | .... I do not grant my agent authority to make any | 23 | | anatomical gifts. | 24 | | C. My agent shall also have full power to authorize an | 25 | | autopsy and direct the disposition of my remains. I intend for | 26 | | this power of attorney to be in substantial compliance with |
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| 1 | | Section 10 of the Disposition of Remains Act. All decisions | 2 | | made by my agent with respect to the disposition of my remains, | 3 | | including cremation, shall be binding. I hereby direct any | 4 | | cemetery organization, business operating a crematory or | 5 | | columbarium or both, funeral director or embalmer, or funeral | 6 | | establishment who receives a copy of this document to act under | 7 | | it. | 8 | | D. I intend for the person named as my agent to be treated | 9 | | as I would be with respect to my rights regarding the use and | 10 | | disclosure of my individually identifiable health information | 11 | | or other medical records, including records or communications | 12 | | governed by the Mental Health and Developmental Disabilities | 13 | | Confidentiality Act. This release authority applies to any | 14 | | information governed by the Health Insurance Portability and | 15 | | Accountability Act of 1996 ("HIPAA") and regulations | 16 | | thereunder. I intend for the person named as my agent to serve | 17 | | as my "personal representative" as that term is defined under | 18 | | HIPAA and regulations thereunder. | 19 | | (i) The person named as my agent shall have the power to | 20 | | authorize the release of information governed by HIPAA to third | 21 | | parties. | 22 | | (ii) I authorize any physician, health care professional, | 23 | | dentist, health plan, hospital, clinic, laboratory, pharmacy | 24 | | or other covered health care provider, any insurance company | 25 | | and the Medical Informational Bureau, Inc., or any other health | 26 | | care clearinghouse that has provided treatment or services to |
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| 1 | | me, or that has paid for or is seeking payment for me for such | 2 | | services to give, disclose, and release to the person named as | 3 | | my agent, without restriction, all of my individually | 4 | | identifiable health information and medical records, regarding | 5 | | any past, present, or future medical or mental health | 6 | | condition, including all information relating to the diagnosis | 7 | | and treatment of HIV/AIDS, sexually transmitted diseases, drug | 8 | | or alcohol abuse, and mental illness (including records or | 9 | | communications governed by the Mental Health and Developmental | 10 | | Disabilities Confidentiality Act). | 11 | | (iii) The authority given to the person named as my agent | 12 | | shall supersede any prior agreement that I may have with my | 13 | | health care providers to restrict access to, or disclosure of, | 14 | | my individually identifiable health information. The authority | 15 | | given to the person named as my agent has no expiration date | 16 | | and shall expire only in the event that I revoke the authority | 17 | | in writing and deliver it to my health care provider. The | 18 | | authority given to the person named as my agent to serve as my | 19 | | "personal representative" as defined under HIPAA and | 20 | | regulations thereunder and to access my individually | 21 | | identifiable health information or authorize the release of the | 22 | | same to third parties shall take effect immediately, even if I | 23 | | designate in Paragraph 3 of this document that this agency | 24 | | shall otherwise take effect at some future date. | 25 | | (NOTE: The above grant of power is intended to be as broad as | 26 | | possible so that your agent will have the authority to make any |
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| 1 | | decision you could make to obtain or terminate any type of | 2 | | health care, including withdrawal of food and water and other | 3 | | life-sustaining measures, if your agent believes such action | 4 | | would be consistent with your intent and desires. If you wish | 5 | | to limit the scope of your agent's powers or prescribe special | 6 | | rules or limit the power to make an anatomical gift, authorize | 7 | | autopsy or dispose of remains, you may do so in the following | 8 | | paragraphs.)
| 9 | | 2. The powers granted above shall not include the following | 10 | | powers or
shall be subject to the following rules or | 11 | | limitations: | 12 | | (NOTE: Here you may include
any specific limitations you deem | 13 | | appropriate, such as: your own
definition of when | 14 | | life-sustaining measures should be withheld; a direction
to | 15 | | continue food and fluids or life-sustaining treatment in
all | 16 | | events; or instructions to refuse
any specific types of | 17 | | treatment that are inconsistent with your religious
beliefs or | 18 | | unacceptable to you for any other reason, such as blood
| 19 | | transfusion, electro-convulsive therapy, amputation, | 20 | | psychosurgery,
voluntary admission to a mental institution, | 21 | | etc.)
| 22 | | .............................................................
| 23 | | .............................................................
| 24 | | .............................................................
| 25 | | .............................................................
| 26 | | .............................................................
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| 1 | | (NOTE: The subject of life-sustaining treatment is of | 2 | | particular importance. For your convenience in dealing with | 3 | | that subject, some general statements concerning the | 4 | | withholding or removal of life-sustaining treatment are set | 5 | | forth below. If you agree with one of these statements, you may | 6 | | initial that statement; but do not initial more than one. These | 7 | | statements serve as guidance for your agent, who shall give | 8 | | careful consideration to the statement you initial when | 9 | | engaging in health care decision-making on your behalf.)
| 10 | | I do not want my life to be prolonged nor do I want | 11 | | life-sustaining
treatment to be provided or continued if my | 12 | | agent believes the burdens of
the treatment outweigh the | 13 | | expected benefits. I want my agent to consider
the relief of | 14 | | suffering, the expense involved and the quality as well as
the | 15 | | possible extension of my life in making decisions concerning
| 16 | | life-sustaining treatment.
| 17 | | Initialed ...........................
| 18 | | I want my life to be prolonged and I want life-sustaining | 19 | | treatment to be
provided or continued, unless I am, in the | 20 | | opinion of my attending physician, in accordance with | 21 | | reasonable medical
standards at the time of reference, in a | 22 | | state of "permanent unconsciousness" or suffer from an | 23 | | "incurable or irreversible condition" or "terminal condition", | 24 | | as those terms are defined in Section 4-4 of the Illinois Power | 25 | | of Attorney Act. If and when I am in any one of these states or | 26 | | conditions, I want life-sustaining treatment to be withheld or
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| 1 | | discontinued.
| 2 | | Initialed ...........................
| 3 | | I want my life to be prolonged to the greatest extent | 4 | | possible in accordance with reasonable medical standards | 5 | | without
regard to my condition, the chances I have for recovery | 6 | | or the cost of the
procedures.
| 7 | | Initialed ...........................
| 8 | | (NOTE: This power of attorney may be amended or revoked by you | 9 | | in the manner provided in Section 4-6 of the Illinois Power of | 10 | | Attorney Act. Your agent can act immediately, unless you | 11 | | specify otherwise; but you cannot specify otherwise with | 12 | | respect to your "personal representative" under subparagraph | 13 | | D(iii). )
| 14 | | 3. This power of attorney shall become effective on
| 15 | | .............................................................
| 16 | | .............................................................
| 17 | | (NOTE: Insert a future date or event during your lifetime, such | 18 | | as a court
determination of your disability or a written | 19 | | determination by your physician that you are incapacitated, | 20 | | when you want this power to first take
effect.)
| 21 | | (NOTE: If you do not amend or revoke this power, or if you do | 22 | | not specify a specific ending date in paragraph 4, it will | 23 | | remain in effect until your death; except that your agent will | 24 | | still have the authority to donate your organs, authorize an | 25 | | autopsy, and dispose of your remains after your death, if you | 26 | | grant that authority to your agent.) |
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| 1 | | 4. This power of attorney shall terminate on
..........
| 2 | | .............................................................
| 3 | | (NOTE: Insert a future date or event, such as a court | 4 | | determination that you are not under a legal disability or a | 5 | | written determination by your physician that you are not | 6 | | incapacitated, if you want this power to terminate prior to | 7 | | your death.)
| 8 | | (NOTE: You cannot use this form to name co-agents. If you wish | 9 | | to name successor agents, insert the names and addresses of the | 10 | | successors in paragraph 5.)
| 11 | | 5. If any agent named by me shall die, become incompetent, | 12 | | resign,
refuse to accept the office of agent or be unavailable, | 13 | | I name
the following (each to act alone
and successively, in | 14 | | the order named) as successors to such agent:
| 15 | | .............................................................
| 16 | | .............................................................
| 17 | | For purposes of this paragraph 5, a person shall be considered | 18 | | to be
incompetent if and while the person is a minor, or an | 19 | | adjudicated
incompetent or disabled person, or the person is | 20 | | unable to give prompt and
intelligent consideration to health | 21 | | care matters, as certified by a licensed physician.
| 22 | | (NOTE: If you wish to, you may name your agent as guardian of | 23 | | your person if a court decides that one should be appointed. To | 24 | | do this, retain paragraph 6, and the court will appoint your | 25 | | agent if the court finds that this appointment will serve your | 26 | | best interests and welfare. Strike out paragraph 6 if you do |
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| 1 | | not want your agent to act as guardian.)
| 2 | | 6. If a guardian of my person is to be appointed, I | 3 | | nominate the agent
acting under this power of attorney as such
| 4 | | guardian, to serve without bond or security.
| 5 | | 7. I am fully informed as to all the contents of this form | 6 | | and
understand the full import of this grant of powers to my | 7 | | agent.
| 8 | | Dated: ..........
| 9 | | Signed ..............................
| 10 | | (principal's signature or mark)
| 11 | | The principal has had an opportunity to review the above | 12 | | form and has
signed the form or acknowledged his or her | 13 | | signature or mark on the form in my presence. The undersigned | 14 | | witness certifies that the witness is not: (a) the attending | 15 | | physician or mental health service provider or a relative of | 16 | | the physician or provider; (b) an owner, operator, or relative | 17 | | of an owner or operator of a health care facility in which the | 18 | | principal is a patient or resident; (c) a parent, sibling, | 19 | | descendant, or any spouse of such parent, sibling, or | 20 | | descendant of either the principal or any agent or successor | 21 | | agent under the foregoing power of attorney, whether such | 22 | | relationship is by blood, marriage, or adoption; or (d) an | 23 | | agent or successor agent under the foregoing power of attorney.
| 24 | | .......................
| 25 | | (Witness Signature)
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| 1 | | .......................
| 2 | | (Print Witness Name)
| 3 | | .......................
| 4 | | (Street Address)
| 5 | | .......................
| 6 | | (City, State, ZIP)
| 7 | | (NOTE: You may, but are not required to, request your agent and | 8 | | successor agents to provide specimen signatures below. If you | 9 | | include specimen signatures in this power of attorney, you must | 10 | | complete the certification opposite the signatures of the | 11 | | agents.)
| 12 | | Specimen signatures of I certify that the signatures of my
| 13 | | agent (and successors). agent (and successors) are correct.
| 14 | | ....................... ...................................
| 15 | | (agent) (principal)
| 16 | | ....................... ...................................
| 17 | | (successor agent) (principal)
| 18 | | ....................... ...................................
| 19 | | (successor agent) (principal)"
| 20 | | (NOTE: The name, address, and phone number of the person | 21 | | preparing this form or who assisted the principal in completing | 22 | | this form is optional.) | 23 | | .........................
| 24 | | (name of preparer)
| 25 | | .........................
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| 1 | | .........................
| 2 | | (address)
| 3 | | .........................
| 4 | | (phone)
| 5 | | (c) The statutory short form power of attorney for health | 6 | | care (the
"statutory health care power") authorizes the agent | 7 | | to make any and all
health care decisions on behalf of the | 8 | | principal which the principal could
make if present and under | 9 | | no disability, subject to any limitations on the
granted powers | 10 | | that appear on the face of the form, to be exercised in such
| 11 | | manner as the agent deems consistent with the intent and | 12 | | desires of the
principal. The agent will be under no duty to | 13 | | exercise granted powers or
to assume control of or | 14 | | responsibility for the principal's health care;
but when | 15 | | granted powers are exercised, the agent will be required to use
| 16 | | due care to act for the benefit of the principal in accordance | 17 | | with the
terms of the statutory health care power and will be | 18 | | liable
for negligent exercise. The agent may act in person or | 19 | | through others
reasonably employed by the agent for that | 20 | | purpose
but may not delegate authority to make health care | 21 | | decisions. The agent
may sign and deliver all instruments, | 22 | | negotiate and enter into all
agreements and do all other acts | 23 | | reasonably necessary to implement the
exercise of the powers | 24 | | granted to the agent. Without limiting the
generality of the | 25 | | foregoing, the statutory health care power shall include
the | 26 | | following powers, subject to any limitations appearing on the |
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| 1 | | face of the form:
| 2 | | (1) The agent is authorized to give consent to and | 3 | | authorize or refuse,
or to withhold or withdraw consent to, | 4 | | any and all types of medical care,
treatment or procedures | 5 | | relating to the physical or mental health of the
principal, | 6 | | including any medication program, surgical procedures,
| 7 | | life-sustaining treatment or provision of food and fluids | 8 | | for the principal.
| 9 | | (2) The agent is authorized to admit the principal to | 10 | | or discharge the
principal from any and all types of | 11 | | hospitals, institutions, homes,
residential or nursing | 12 | | facilities, treatment centers and other health care
| 13 | | institutions providing personal care or treatment for any | 14 | | type of physical
or mental condition. The agent shall have | 15 | | the same right to visit the
principal in the hospital or | 16 | | other institution as is granted to a spouse or
adult child | 17 | | of the principal, any rule of the institution to the | 18 | | contrary
notwithstanding.
| 19 | | (3) The agent is authorized to contract for any and all | 20 | | types of health
care services and facilities in the name of | 21 | | and on behalf of the principal
and to bind the principal to | 22 | | pay for all such services and facilities,
and to have and | 23 | | exercise those powers over the principal's property as are
| 24 | | authorized under the statutory property power, to the | 25 | | extent the agent
deems necessary to pay health care costs; | 26 | | and
the agent shall not be personally liable for any |
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| 1 | | services or care contracted
for on behalf of the principal.
| 2 | | (4) At the principal's expense and subject to | 3 | | reasonable rules of the
health care provider to prevent | 4 | | disruption of the principal's health care,
the agent shall | 5 | | have the same right the principal has to examine and copy
| 6 | | and consent to disclosure of all the principal's medical | 7 | | records that the agent deems
relevant to the exercise of | 8 | | the agent's powers, whether the records
relate to mental | 9 | | health or any other medical condition and whether they are | 10 | | in
the possession of or maintained by any physician, | 11 | | psychiatrist,
psychologist, therapist, hospital, nursing | 12 | | home or other health care
provider.
| 13 | | (5) The agent is authorized: to direct that an autopsy | 14 | | be made pursuant
to Section 2 of "An Act in relation to | 15 | | autopsy of dead bodies", approved
August 13, 1965, | 16 | | including all amendments;
to make a disposition of any
part | 17 | | or all of the principal's body pursuant to the Illinois | 18 | | Anatomical Gift
Act, as now or hereafter amended; and to | 19 | | direct the disposition of the
principal's remains.
| 20 | | (Source: P.A. 96-1195, eff. 7-1-11.)
| 21 | | Section 99. Effective date. This Act takes effect July 1, | 22 | | 2011.
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