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 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. 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 organ:
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 limita-
tions (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.):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
(continued)
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Illinois Statutory Short Form Power of Attorney for Health Care PDF

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