Public Act 097-0148
 
SB1877 EnrolledLRB097 09886 AJO 50046 b


  
    AN ACT concerning civil law.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  
 
 
    Section 5. The Illinois Power of Attorney Act is amended  by 
changing Section 4-10 as follows:
 


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



    (Text of Section before amendment by P.A. 96-1195)

    Sec. 4-10. Statutory short form power of attorney for 
health care. 

    (a) The following form (sometimes also referred to in this 
Act as the
"statutory health care power") may be used to grant 
an agent powers with
respect to the principal's own health 
care; but the statutory health care
power is not intended to be 
exclusive nor to cover delegation of a parent's
power to 
control the health care of a minor child, and no provision of 
this
Article shall be construed to invalidate or bar use by the 
principal of any
other or
different form of power of attorney 
for health care.  Nonstatutory health
care powers must be

executed by the principal, designate the agent and the agent's 
powers, and
comply with Section 4-5 of this Article, but they 
need not be witnessed or
conform in any other respect to the 
statutory health care power. When a
power of attorney in 
substantially the
following form is used, including the 
"notice" paragraph at the beginning
in capital letters, it 
shall have the meaning and effect prescribed in this
Act.  The 
statutory health care power may be included in or
combined with 
any
other form of power of attorney governing property or other 
matters.

    "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH 
CARE

    (NOTICE:  THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE 
THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE 
HEALTH CARE DECISIONS FOR YOU,
INCLUDING POWER TO REQUIRE, 
CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL
CARE OR MEDICAL 
TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT
YOU 
TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER 
INSTITUTION.  THIS
FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO 
EXERCISE GRANTED POWERS; BUT
WHEN POWERS ARE EXERCISED, YOUR 
AGENT WILL HAVE TO USE
DUE CARE TO ACT FOR
YOUR BENEFIT AND IN 
ACCORDANCE WITH  THIS FORM AND KEEP A RECORD OF
RECEIPTS, 
DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT.  A COURT

CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS 
NOT ACTING PROPERLY.  YOU MAY
NAME SUCCESSOR AGENTS UNDER THIS 
FORM
BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE 
NAMED.  UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER
IN 
THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A 
COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY 
EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN 
AFTER YOU BECOME DISABLED.  THE POWERS YOU
GIVE YOUR AGENT, YOUR 
RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR
VIOLATING 
THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND

4-10(b) OF THE ILLINOIS
"POWERS OF ATTORNEY FOR HEALTH CARE 
LAW"
OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM).  
THAT LAW
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF 
POWER OF ATTORNEY YOU
MAY DESIRE.  IF THERE IS ANYTHING ABOUT 
THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER 
TO EXPLAIN IT TO YOU.)

    POWER OF ATTORNEY made this .......................day of

................................

    (month)  (year)

    1. I, ..................................................,

              (insert name and address of principal)

hereby appoint:

............................................................

          (insert name and address of agent)

as my attorney-in-fact (my "agent") to act for me and in my 
name (in any
way I could act in person) to make any and all 
decisions for me concerning
my personal care, medical 
treatment, hospitalization and health care and to
require, 
withhold or withdraw any type of medical treatment or 
procedure,
even though my death may ensue.  My agent shall have 
the same access to my
medical records that I have, including 
the right to disclose the contents
to others.  My agent shall 
also have full power to
authorize an autopsy and direct the 
disposition of my remains.
Effective upon my death, my agent 
has the full power to make an anatomical
gift of the following 
(initial one):


        ....Any organs, tissues, or eyes suitable for 
    transplantation or used for
research or education.


        ....Specific organs:.................................

(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS 
POSSIBLE SO THAT
YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY 
DECISION YOU COULD MAKE TO
OBTAIN OR TERMINATE ANY TYPE OF 
HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD
AND WATER AND OTHER 
LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH
ACTION 
WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES.  IF YOU WISH 
TO
LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE SPECIAL 
RULES OR LIMIT
THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE 
AUTOPSY OR DISPOSE OF
REMAINS, YOU MAY DO SO IN THE FOLLOWING 
PARAGRAPHS.)

    2. The powers granted above shall not include the following 
powers or
shall be subject to the following rules or 
limitations (here you may include
any specific limitations you 
deem appropriate, such as:  your own
definition of when 
life-sustaining measures should be withheld; a direction
to 
continue food and fluids or life-sustaining treatment in
all 
events; or instructions to refuse
any specific types of 
treatment that are inconsistent with your religious
beliefs or 
unacceptable to you for any other reason, such as blood

transfusion, electro-convulsive therapy, amputation, 
psychosurgery,
voluntary admission to a mental institution, 
etc.):

.............................................................

.............................................................

.............................................................

.............................................................

.............................................................

(THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR 
IMPORTANCE.  FOR
YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, 
SOME GENERAL STATEMENTS
CONCERNING THE WITHHOLDING OR REMOVAL 
OF LIFE-SUSTAINING TREATMENT ARE SET
FORTH BELOW.  IF YOU AGREE 
WITH ONE OF THESE STATEMENTS, YOU MAY
INITIAL THAT STATEMENT; 
BUT DO NOT INITIAL MORE THAN ONE):

    I do not want my life to be prolonged nor do I want 
life-sustaining
treatment to be provided or continued if my 
agent believes the burdens of
the treatment outweigh the 
expected benefits.  I want my agent to consider
the relief of 
suffering, the expense involved and the quality as well as
the 
possible extension of my life in making decisions concerning

life-sustaining treatment.

Initialed...........................


    I want my life to be prolonged and I want life-sustaining 
treatment to be
provided or continued unless I am in a coma 
which my attending physician
believes to be irreversible, in 
accordance with reasonable medical
standards at the time of 
reference.  If and when I have suffered
irreversible coma, I 
want life-sustaining treatment to be withheld or
discontinued.

Initialed...........................


    I want my life to be prolonged to the greatest extent 
possible without
regard to my condition, the chances I have for 
recovery or the cost of the
procedures.

Initialed...........................


(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE 
MANNER
PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF 
ATTORNEY FOR HEALTH CARE
LAW" (SEE THE BACK OF THIS FORM).  
ABSENT AMENDMENT OR
REVOCATION, THE AUTHORITY GRANTED IN THIS

POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER 
IS SIGNED
AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF 
ANATOMICAL GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS 
AUTHORIZED, UNLESS A LIMITATION ON THE
BEGINNING DATE OR 
DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR
BOTH OF 
THE FOLLOWING:)

    3.  ( ) This power of attorney shall become effective on

.............................................................

.............................................................

(insert a future date or event during your lifetime, such as 
court
determination of your disability, when you want this 
power to first take
effect)

    4.  ( ) This power of attorney shall terminate on
.......

.............................................................

(insert a future date or event, such as court determination of 
your
disability, when you want this power to terminate prior to 
your death)

(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND 
ADDRESSES OF
SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)

    5. If any agent named by me shall die, become incompetent, 
resign,
refuse to accept the office of agent or be unavailable, 
I name
the following (each to act alone
and successively, in 
the order named) as successors to such agent:

.............................................................

.............................................................

For purposes of this paragraph 5, a person shall be considered 
to be
incompetent if and while the person is a minor or an 
adjudicated
incompetent or disabled person or the person is 
unable to give prompt and
intelligent consideration to health 
care matters, as certified by a licensed physician.
(IF YOU 
WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON,
IN THE 
EVENT A COURT DECIDES
THAT ONE SHOULD BE APPOINTED, YOU MAY, 
BUT ARE NOT REQUIRED TO, DO SO BY
RETAINING THE FOLLOWING

PARAGRAPH.  THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS 
THAT SUCH
APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND 
WELFARE.  STRIKE OUT
PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT 
TO ACT AS GUARDIAN.)

    6. If a guardian of my person is to be appointed, I 
nominate the agent
acting under this power of attorney as such

guardian, to serve without bond or security.

    7. I am fully informed as to all the contents of this form 
and
understand the full import of this grant of powers to my 
agent.

Signed..............................


             
(principal)
      

    The principal has had an opportunity to read the above form 
and has
signed the form or acknowledged his or her signature or 
mark on the form in my presence.

..........................  Residing at......................

        (witness)

(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND 
SUCCESSOR AGENTS
TO PROVIDE SPECIMEN SIGNATURES BELOW.  IF YOU 
INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST 
COMPLETE THE CERTIFICATION OPPOSITE THE
SIGNATURES OF THE 
AGENTS.)

Specimen signatures of    I certify that the signatures of my

agent (and successors).   agent (and successors) are correct.

.......................   ...................................

       (agent)                      (principal)

.......................   ...................................

   (successor agent)                (principal)

.......................   ...................................

   (successor agent)                (principal)"

    (b) The statutory short form power of attorney for health 
care (the
"statutory health care power") authorizes the agent 
to make any and all
health care decisions on behalf of the 
principal which the principal could
make if present and under 
no disability, subject to any limitations on the
granted powers 
that appear on the face of the form, to be exercised in such

manner as the agent deems consistent with the intent and 
desires of the
principal.  The agent will be under no duty to 
exercise granted powers or
to assume control of or 
responsibility for the  principal's health care;
but when 
granted powers are exercised, the agent will be required to use

due care to act for the benefit of the principal in accordance 
with the
terms of the statutory health care power and will be 
liable
for negligent exercise.   The agent may act in person or 
through others
reasonably employed by the agent for that 
purpose
but may not delegate authority to make health care 
decisions.  The agent
may sign and deliver all instruments, 
negotiate and enter into all
agreements and do all other acts 
reasonably necessary to implement the
exercise of the powers 
granted to the agent.  Without limiting the
generality of the 
foregoing, the statutory health care power shall include
the 
following powers, subject to any limitations appearing on the 
face of the form:

        (1) The agent is authorized to give consent to and 
    authorize or refuse,
or to withhold or withdraw consent to, 
    any and all types of medical care,
treatment or procedures 
    relating to the physical or mental health of the
principal, 
    including any medication program, surgical procedures,

    life-sustaining treatment or provision of food and fluids 
    for the principal.

        (2) The agent is authorized to admit the principal to 
    or discharge the
principal from any and all types of 
    hospitals, institutions, homes,
residential or nursing 
    facilities, treatment centers and other health care

    institutions providing personal care or treatment for any 
    type of physical
or mental condition.  The agent shall have 
    the same right to visit the
principal in the hospital or 
    other institution as is granted to a spouse or
adult child 
    of the principal, any rule of the institution to the 
    contrary
notwithstanding.

        (3) The agent is authorized to contract for any and all 
    types of health
care services and facilities in the name of 
    and on behalf of the principal
and to bind the principal to 
    pay for all such services and facilities,
and to have and 
    exercise those powers over the principal's property as are

    authorized under the statutory property power, to the 
    extent the agent
deems necessary to pay health care costs; 
    and
the agent shall not be personally liable for any 
    services or care contracted
for on behalf of the principal.

        (4) At the principal's expense and subject to 
    reasonable rules of the
health care provider to prevent 
    disruption of the principal's health care,
the agent shall 
    have the same right the principal has to examine and copy

    and consent to disclosure of all the principal's medical 
    records that the agent deems
relevant to the exercise of 
    the agent's powers, whether the records
relate to mental 
    health or any other medical condition and whether they are 
    in
the possession of or maintained by any physician, 
    psychiatrist,
psychologist, therapist, hospital, nursing 
    home or other health care
provider.

        (5) The agent is authorized: to direct that an autopsy 
    be made pursuant
to Section 2 of "An Act in relation to 
    autopsy of dead bodies", approved
August 13, 1965, 
    including all amendments;
to make a disposition of any
part 
    or all of the principal's body pursuant to the Illinois 
    Anatomical Gift
Act, as now or hereafter amended; and to 
    direct the disposition of the
principal's remains.

(Source: P.A. 93-794, eff. 7-22-04.)

 
    (Text of Section after amendment by P.A. 96-1195)

    Sec. 4-10. Statutory short form power of attorney for 
health care. 

    (a) The form prescribed in this Section (sometimes also 
referred to in this Act as the
"statutory health care power") 
may be used to grant an agent powers with
respect to the 
principal's own health care; but the statutory health care

power is not intended to be exclusive nor to cover delegation 
of a parent's
power to control the health care of a minor 
child, and no provision of this
Article shall be construed to 
invalidate or bar use by the principal of any
other or

different form of power of attorney for health care.  
Nonstatutory health
care powers must be
executed by the 
principal, designate the agent and the agent's powers, and

comply with Section 4-5 of this Article, but they need not be 
witnessed or
conform in any other respect to the statutory 
health care power. When a
power of attorney in substantially 
the
 form prescribed in this Section is used, including the 
"Notice to the Individual Signing the Illinois Statutory Short 
Form Power of Attorney for Health Care" (or "Notice" 
paragraphs) at the beginning of the form on a separate sheet in 
14-point type, it shall have the meaning and effect prescribed 
in this
Act. A power of attorney for health care shall be 
deemed to be in substantially the same format as the statutory 
form if the explanatory language throughout the form (the 
language following the designation "NOTE:") is distinguished 
in some way from the legal paragraphs in the form, such as the 
use of boldface or other difference in typeface and font or 
point size, even if the "Notice" paragraphs at the beginning 
are not on a separate sheet of paper or are not in 14-point 
type, or if the principal's initials do not appear in the 
acknowledgement at the end of the "Notice" paragraphs.  The 
statutory health care power may be included in or
combined with 
any
other form of power of attorney governing property or other 
matters.

    (b) The Illinois Statutory Short Form Power of Attorney for 
Health Care shall be substantially as follows: 
 
"NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS  
  
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE 

 
    PLEASE READ THIS NOTICE CAREFULLY.  The form that you will 
be signing is a legal document.  It is governed by the Illinois 
Power of Attorney Act.  If there is anything about this form 
that you do not understand, you should ask a lawyer to explain 
it to you.
    The purpose of this Power of Attorney is to give your 
designated "agent" broad powers to make health care decisions 
for you, including the power to require, consent to, or 
withdraw treatment for any physical or mental condition, and to 
admit you or discharge you from any hospital, home, or other 
institution. You may name successor agents under this form, but 
you may not name co-agents.
    This form does not impose a duty upon your agent to make 
such health care decisions, so it is important that you select 
an agent who will agree to do this for you and who will make 
those decisions as you would wish.  It is also important to 
select an agent whom you trust, since you are giving that agent 
control over your medical decision-making, including 
end-of-life decisions.  Any agent who does act for you has a 
duty to act in good faith for your benefit and to use due care, 
competence, and diligence.  He or she must also act in 
accordance with the law and with the statements in this form.  
Your agent must keep a record of all significant actions taken 
as your agent.
    Unless you specifically limit the period of time that this 
Power of Attorney will be in effect, your agent may exercise 
the powers given to him or her throughout your lifetime, even 
after you become disabled.  A court, however, can take away the 
powers of your agent if it finds that the agent is not acting 
properly.  You may also revoke this Power of Attorney if you 
wish.
    The Powers you give your agent, your right to revoke those 
powers, and the penalties for violating the law are explained 
more fully in Sections 4-5, 4-6, and 4-10(c) 4-10(b)  of the 
Illinois Power of Attorney Act. This form is a part of that 
law.  The "NOTE" paragraphs throughout this form are 
instructions.
    You are not required to sign this Power of Attorney, but it 
will not take effect without your signature.  You should not 
sign it if you do not understand everything in it, and what 
your agent will be able to do if you do sign it.
 
    Please put your initials on the following line indicating 
that you have read this Notice: 
...................... 
(Principal's initials)" 

 
"ILLINOIS STATUTORY SHORT FORM
  
POWER OF ATTORNEY FOR HEALTH CARE


 


    1. I, ..................................................,
              
(insert name and address of principal)
hereby revoke all prior 
powers of attorney for health care executed by me and appoint:

............................................................
          
(insert name and address of agent)

(NOTE: You may not name co-agents using this form.) 
as my attorney-in-fact (my "agent") to act for me and in my 
name (in any
way I could act in person) to make any and all 
decisions for me concerning
my personal care, medical 
treatment, hospitalization and health care and to
require, 
withhold or withdraw any type of medical treatment or 
procedure,
even though my death may ensue.
    A.  My agent shall have the same access to my
medical 
records that I have, including the right to disclose the 
contents
to others.  
    B.
Effective upon my death, my agent has the full power to 
make an anatomical
gift of the following: 
(NOTE: Initial one. In the event none of the options are 
initialed, then it shall be concluded that you do not wish to 
grant your agent any such authority.)


        .... Any organs, tissues, or eyes suitable for 
    transplantation or used for
research or education.


        .... Specific organs:................................

        .... I do not grant my agent authority to make any 
    anatomical gifts. 
    C. My agent shall also have full power to authorize an 
autopsy and direct the disposition of my remains. I intend for 
this power of attorney to be in substantial compliance with 
Section 10 of the Disposition of Remains Act. All decisions 
made by my agent with respect to the disposition of my remains, 
including cremation, shall be binding. I hereby direct any 
cemetery organization, business operating a crematory or 
columbarium or both, funeral director or embalmer, or funeral 
establishment who receives a copy of this document to act under 
it.
    D. I intend for the person named as my agent to be treated 
as I would be with respect to my rights regarding the use and 
disclosure of my individually identifiable health information 
or other medical records, including records or communications 
governed by the Mental Health and Developmental Disabilities 
Confidentiality Act.  This release authority applies to any 
information governed by the Health Insurance Portability and 
Accountability Act of 1996 ("HIPAA") and regulations 
thereunder. I intend for the person named as my agent to serve 
as my "personal representative" as that term is defined under 
HIPAA and regulations thereunder.
    (i) The person named as my agent shall have the power to 
authorize the release of information governed by HIPAA to third 
parties.
    (ii) I authorize any physician, health care professional, 
dentist, health plan, hospital, clinic, laboratory, pharmacy 
or other covered health care provider, any insurance company 
and the Medical Informational Bureau, Inc., or any other health 
care clearinghouse that has provided treatment or services to 
me, or that has paid for or is seeking payment for me for such 
services to give, disclose, and release to the person named as 
my agent, without restriction, all of my individually 
identifiable health information and medical records, regarding 
any past, present, or future medical or mental health 
condition, including all information relating to the diagnosis 
and treatment of HIV/AIDS, sexually transmitted diseases, drug 
or alcohol abuse, and mental illness (including records or 
communications governed by the Mental Health and Developmental 
Disabilities Confidentiality Act).
    (iii) The authority given to the person named as my agent 
shall supersede any prior agreement that I may have with my 
health care providers to restrict access to, or disclosure of, 
my individually identifiable health information.  The authority 
given to the person named as my agent has no expiration date 
and shall expire only in the event that I revoke the authority 
in writing and deliver it to my health care provider.  The 
authority given to the person named as my agent to serve as my 
"personal representative" as defined under HIPAA and 
regulations thereunder and to access my individually 
identifiable health information or authorize the release of the 
same to third parties shall take effect immediately, even if I 
designate in Paragraph 3 of this document that this agency 
shall otherwise take effect at some future date. 
(NOTE: The above grant of power is intended to be as broad as 
possible so that your agent will have the authority to make any 
decision you could make to obtain or terminate any type of 
health care, including withdrawal of food and water and other 
life-sustaining measures, if your agent believes such action 
would be consistent with your intent and desires.  If you wish 
to limit the scope of your agent's powers or prescribe special 
rules or limit the power to make an anatomical gift, authorize 
autopsy or dispose of remains, you may do so in the following 
paragraphs.) 

    2. The powers granted above shall not include the following 
powers or
shall be subject to the following rules or 
limitations:
(NOTE: Here  you may include
any specific limitations you deem 
appropriate, such as:  your own
definition of when 
life-sustaining measures should be withheld; a direction
to 
continue food and fluids or life-sustaining treatment in
all 
events; or instructions to refuse
any specific types of 
treatment that are inconsistent with your religious
beliefs or 
unacceptable to you for any other reason, such as blood

transfusion, electro-convulsive therapy, amputation, 
psychosurgery,
voluntary admission to a mental institution, 
etc.) 

.............................................................

.............................................................

.............................................................

.............................................................

.............................................................

(NOTE: The subject of life-sustaining treatment is of 
particular importance.  For your convenience in dealing with 
that subject, some general statements concerning the 
withholding or removal of life-sustaining treatment are set 
forth below.  If you agree with one of these statements, you may 
initial that statement; but do not initial more than one. These 
statements serve as guidance for your agent, who shall give 
careful consideration to the statement you initial when 
engaging in health care decision-making on your behalf.) 

    I do not want my life to be prolonged nor do I want 
life-sustaining
treatment to be provided or continued if my 
agent believes the burdens of
the treatment outweigh the 
expected benefits.  I want my agent to consider
the relief of 
suffering, the expense involved and the quality as well as
the 
possible extension of my life in making decisions concerning

life-sustaining treatment.

Initialed ...........................


    I want my life to be prolonged and I want life-sustaining 
treatment to be
provided or continued, unless I am, in the 
opinion of my attending physician, in accordance with 
reasonable medical
standards at the time of reference, in a 
state of "permanent unconsciousness" or suffer from an 
"incurable or irreversible condition" or "terminal condition", 
as those terms are defined in Section 4-4 of the Illinois Power 
of Attorney Act.  If and when I am in  any one of these states or 
conditions,  I want life-sustaining treatment to be withheld or

discontinued. 

Initialed ...........................


    I want my life to be prolonged to the greatest extent 
possible in accordance with reasonable medical standards 
without
regard to my condition, the chances I have for recovery 
or the cost of the
procedures.

Initialed ...........................


(NOTE: This power of attorney may be amended or revoked by you 
in the manner provided in Section 4-6 of the Illinois Power of 
Attorney Act.  Your agent can act immediately, unless you 
specify otherwise; but you cannot specify otherwise with 
respect to your "personal representative" under subparagraph 
D(iii).) 

    3.   This power of attorney shall become effective on

.............................................................

.............................................................

(NOTE: Insert  a future date or event during your lifetime, such 
as a court
determination of your disability or a written 
determination by your physician that you are incapacitated, 
when you want this power to first take
effect.)

(NOTE: If you do not amend or revoke this power, or if you do 
not specify a specific ending date in paragraph 4, it will 
remain in effect until your death; except that your agent will 
still have the authority to donate your organs, authorize an 
autopsy, and dispose of your remains after your death, if you 
grant that authority to your agent.) 
    4.   This power of attorney shall terminate on
..........

.............................................................

(NOTE: Insert  a future date or event, such as a court 
determination that you are not under a legal disability or a 
written determination by your physician that you are not 
incapacitated, if  you want this power to terminate prior to 
your death.)

(NOTE: You cannot use this form to name co-agents. If you wish 
to name successor agents, insert the names and addresses of the 
successors in paragraph 5.) 

    5. If any agent named by me shall die, become incompetent, 
resign,
refuse to accept the office of agent or be unavailable, 
I name
the following (each to act alone
and successively, in 
the order named) as successors to such agent:

.............................................................

.............................................................

For purposes of this paragraph 5, a person shall be considered 
to be
incompetent if and while the person is a minor, or an 
adjudicated
incompetent or disabled person, or the person is 
unable to give prompt and
intelligent consideration to health 
care matters, as certified by a licensed physician.

(NOTE: If you wish to, you may name your agent as guardian of 
your person if a court decides that one should be appointed. To 
do this, retain paragraph 6, and the court will appoint your 
agent if the court finds that this appointment will serve your 
best interests and welfare.  Strike out paragraph 6 if you do 
not want your agent to act as guardian.)

    6. If a guardian of my person is to be appointed, I 
nominate the agent
acting under this power of attorney as such

guardian, to serve without bond or security.

    7. I am fully informed as to all the contents of this form 
and
understand the full import of this grant of powers to my 
agent.

Dated: .......... 
 
Signed ..............................


             
(principal's signature or mark)
  

 
    The principal has had an opportunity to review  the above 
form and has
signed the form or acknowledged his or her 
signature or mark on the form in my presence. The undersigned 
witness certifies that the witness is not: (a) the attending 
physician or mental health service provider or a relative of 
the physician or provider; (b) an owner, operator, or relative 
of an owner or operator of a health care facility in which the 
principal is a patient or resident; (c) a parent, sibling, 
descendant, or any spouse of such parent, sibling, or 
descendant of either the principal or any agent or successor 
agent under the foregoing power of attorney, whether such 
relationship is by blood, marriage, or adoption; or (d) an 
agent or successor agent under the foregoing power of attorney. 

   
.......................
(Witness Signature)
.......................
(Print Witness Name)
.......................
(Street Address)
.......................
(City, State, ZIP)


(NOTE: You may, but are not required to, request your agent and 
successor agents to provide specimen signatures below.  If you 
include specimen signatures in this power of attorney, you must 
complete the certification opposite the signatures of the 
agents.) 

Specimen signatures of    I certify that the signatures of my

agent (and successors).   agent (and successors) are correct.

.......................   ...................................

       (agent)                      (principal)

.......................   ...................................

   (successor agent)                (principal)

.......................   ...................................

   (successor agent)                (principal)"

 
    (NOTE: The name, address, and phone number of the person 
preparing this form or who assisted the principal in completing 
this form is optional.) 
......................... 
(name of preparer) 
......................... 
......................... 
(address) 
......................... 
(phone) 
    (c)  The statutory short form power of attorney for health 
care (the
"statutory health care power") authorizes the agent 
to make any and all
health care decisions on behalf of the 
principal which the principal could
make if present and under 
no disability, subject to any limitations on the
granted powers 
that appear on the face of the form, to be exercised in such

manner as the agent deems consistent with the intent and 
desires of the
principal.  The agent will be under no duty to 
exercise granted powers or
to assume control of or 
responsibility for the  principal's health care;
but when 
granted powers are exercised, the agent will be required to use

due care to act for the benefit of the principal in accordance 
with the
terms of the statutory health care power and will be 
liable
for negligent exercise.   The agent may act in person or 
through others
reasonably employed by the agent for that 
purpose
but may not delegate authority to make health care 
decisions.  The agent
may sign and deliver all instruments, 
negotiate and enter into all
agreements and do all other acts 
reasonably necessary to implement the
exercise of the powers 
granted to the agent.  Without limiting the
generality of the 
foregoing, the statutory health care power shall include
the 
following powers, subject to any limitations appearing on the 
face of the form:

        (1) The agent is authorized to give consent to and 
    authorize or refuse,
or to withhold or withdraw consent to, 
    any and all types of medical care,
treatment or procedures 
    relating to the physical or mental health of the
principal, 
    including any medication program, surgical procedures,

    life-sustaining treatment or provision of food and fluids 
    for the principal.

        (2) The agent is authorized to admit the principal to 
    or discharge the
principal from any and all types of 
    hospitals, institutions, homes,
residential or nursing 
    facilities, treatment centers and other health care

    institutions providing personal care or treatment for any 
    type of physical
or mental condition.  The agent shall have 
    the same right to visit the
principal in the hospital or 
    other institution as is granted to a spouse or
adult child 
    of the principal, any rule of the institution to the 
    contrary
notwithstanding.

        (3) The agent is authorized to contract for any and all 
    types of health
care services and facilities in the name of 
    and on behalf of the principal
and to bind the principal to 
    pay for all such services and facilities,
and to have and 
    exercise those powers over the principal's property as are

    authorized under the statutory property power, to the 
    extent the agent
deems necessary to pay health care costs; 
    and
the agent shall not be personally liable for any 
    services or care contracted
for on behalf of the principal.

        (4) At the principal's expense and subject to 
    reasonable rules of the
health care provider to prevent 
    disruption of the principal's health care,
the agent shall 
    have the same right the principal has to examine and copy

    and consent to disclosure of all the principal's medical 
    records that the agent deems
relevant to the exercise of 
    the agent's powers, whether the records
relate to mental 
    health or any other medical condition and whether they are 
    in
the possession of or maintained by any physician, 
    psychiatrist,
psychologist, therapist, hospital, nursing 
    home or other health care
provider.

        (5) The agent is authorized: to direct that an autopsy 
    be made pursuant
to Section 2 of "An Act in relation to 
    autopsy of dead bodies", approved
August 13, 1965, 
    including all amendments;
to make a disposition of any
part 
    or all of the principal's body pursuant to the Illinois 
    Anatomical Gift
Act, as now or hereafter amended; and to 
    direct the disposition of the
principal's remains.

(Source: P.A. 96-1195, eff. 7-1-11.)

 
 
    Section 99. Effective date. This Act takes effect July 1, 
2011. 
  


Effective Date:  7/14/2011