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
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 benet 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 signicant actions taken
as your agent.
Unless you specically 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 nds 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) of the Illinois Power
of Attorney Act. This form is a part of that law. The “NOTE” paragraphs throughout this form
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: