The Illinois Short Power of Attorney for Health Care is a legal document that allows an individual to appoint an agent to make health care decisions on their behalf. This form grants the agent broad authority to make choices regarding medical treatment, hospitalization, and end-of-life care, reflecting the principal's wishes. Understanding this document is crucial, as it empowers someone you trust to act in your best interests during critical health situations.
The Illinois Short Power of Attorney for Health Care is a crucial legal document that allows individuals to designate an agent to make health care decisions on their behalf. This form is governed by the Illinois Power of Attorney Act and is designed to ensure that your medical preferences are respected, even if you become unable to communicate them yourself. By signing this document, you grant your chosen agent the authority to make decisions regarding your medical treatment, hospitalization, and even end-of-life care. It’s important to choose someone you trust, as this person will have significant control over your health care choices. The form also provides the option to name successor agents, ensuring that your wishes can still be honored if your primary agent is unavailable. While your agent is not obligated to act, they are expected to do so in good faith and with diligence. Additionally, the document allows for the management of your medical records and includes provisions for anatomical gifts and the disposition of remains after death. Understanding the implications of this form is essential, as it remains effective throughout your lifetime unless revoked or limited by you. This article will delve deeper into the specifics of the Illinois Short Power of Attorney for Health Care, highlighting its importance and the responsibilities it entails for both the principal and the agent.
What is the purpose of the Illinois Short Power of Attorney for Health Care?
The Illinois Short Power of Attorney for Health Care allows you to appoint someone, known as your agent, to make health care decisions on your behalf. This includes the ability to consent to or withdraw medical treatment, admit or discharge you from hospitals or care facilities, and even make decisions regarding end-of-life care. It’s designed to ensure that your medical preferences are honored when you may not be able to communicate them yourself.
Can I choose more than one agent using this form?
No, this form does not allow for the appointment of co-agents. You can designate only one agent to act on your behalf. However, you can name successor agents. These are individuals who can step in if your primary agent is unable or unwilling to serve. It’s essential to select someone you trust completely, as they will have significant authority over your medical decisions.
What happens if I want to revoke the Power of Attorney?
You have the right to revoke the Power of Attorney at any time. To do so, you need to provide a written notice of revocation to your agent and any relevant health care providers. It’s a straightforward process, but it’s crucial to ensure that all parties involved are aware of the change. Keep in mind that your agent can only act on your behalf as long as the Power of Attorney is in effect.
How long does the Power of Attorney remain in effect?
The Power of Attorney will remain in effect throughout your lifetime unless you specify a different termination date or event. If you do not set a specific end date, it will continue to be valid until your death. However, your agent retains authority to make decisions even after your passing, if you have granted them that power regarding anatomical gifts or the disposition of your remains.
Not Reading the Notice Carefully: Failing to read the notice at the beginning of the form can lead to misunderstandings about the powers being granted.
Not Initialing the Notice: Forgetting to put initials on the line provided indicates that you did not read the notice, which is an important step in the process.
Inaccurate Information: Providing incorrect names or addresses for yourself or your agent can create legal issues and invalidate the document.
Naming Co-Agents: Attempting to name co-agents is a mistake, as this form specifically prohibits it. Only one agent can be designated.
Not Specifying Limitations: Failing to include any specific limitations on your agent’s powers can lead to unintended decisions being made on your behalf.
Ignoring the Anatomical Gift Section: Overlooking the section about anatomical gifts may result in your agent not having the authority to make decisions regarding organ donation.
Leaving the Effective Date Blank: Not specifying when the power of attorney becomes effective can lead to confusion about when your agent can act on your behalf.
Not Including a Termination Date: Failing to specify when the power of attorney will terminate can leave your agent with authority indefinitely.
Not Naming Successor Agents: If your primary agent is unable to act, not naming successor agents can leave you without representation.
Not Understanding the Document: Signing the form without fully understanding its implications can lead to significant consequences regarding your health care decisions.
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 beneit 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 signiicant actions taken as your agent.
Unless you speciically 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 inds 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 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)
A-1
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.
______ Speciic 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.
B-1
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 identiiable health information or other medical records, including records or communications governed by the Mental Health and Developmental Disabilities Conidentiality 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 deined 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 identiiable 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 Conidentiality 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 identiiable 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.
(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.)
B-2
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 speciic limitations you deem appropriate, such as: your own deinition of when life-sustaining measures should be withheld; a direction to continue food and luids or life-sustaining treatment in all events; or instructions to refuse any speciic 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 beneits. 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 deined 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.
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.
B-3
(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. )
3.This power of attorney shall become effective on: _________________________________
(NOTE: In Line 3 above, 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 irst take effect.)
(NOTE: If you do not amend or revoke this power, or if you do not specify a speciic 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: In Line 4 above, 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 ofice of agent or be unavailable, I name the following (each to act alone and successively, in the order named) as successors to such agent:
(insert name and address of successor 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 certiied 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 inds 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)
B-4
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 certiies 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 or 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 certiication opposite the signatures of the agents.)
Specimen signatures of agent (and successors).
I certify that the signatures of my agent (and
successors) are correct.
________________________________________
(agent)
(principal)
(successor agent)
(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)
B-5
When filling out the Illinois Short Power of Attorney form, it is crucial to approach the task with care and attention to detail. Below is a list of things you should and shouldn't do to ensure that the document is completed correctly and effectively.
When considering the Illinois Short Power of Attorney for Health Care, it is essential to understand the various forms and documents that may accompany it. Each of these documents serves a specific purpose and can help ensure that your health care wishes are respected. Below is a list of commonly used documents that complement the Illinois Short Power of Attorney.
Understanding these documents can empower you to make informed decisions about your health care and financial matters. It is advisable to consult with a legal professional to ensure that your wishes are clearly articulated and legally binding.
This form is relevant for anyone who wishes to designate someone to make health care decisions on their behalf, regardless of age. It is a proactive step for anyone concerned about their medical care.
While the agent has broad powers, the principal can set specific limitations within the form. This ensures that the agent's authority aligns with the principal's wishes.
While the agent is required to act in good faith, their interpretation of what constitutes the principal’s best interest may differ. Clear communication and trust are crucial.
The power of attorney ceases upon the principal's death. However, if authorized, the agent can make decisions regarding organ donation and the disposition of remains after the principal has passed.
This form does not allow for co-agents. The principal can name successor agents, but only one agent can act at a time.
The principal retains the right to revoke the power of attorney at any time. Additionally, the principal can specify conditions under which the agent may act, maintaining a level of control over their health care decisions.
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