The Illinois Short Power form is an essential legal document designed to empower a designated individual, known as an "agent," with the authority to make critical healthcare decisions on behalf of the form's signatory in circumstances where they might not be able to do so themselves. Governed by the Illinois Power of Attorney Act, it lays out a framework for the delegation of decision-making powers ranging from medical treatment consent to end-of-life care preferences. Understanding and meticulously selecting the right agent is crucial since the form entrusts them with significant control over one's health care decisions, including life-sustaining treatments. For those ready to take this step, ensuring you have thoroughly read and understood each part of the form is critical before proceeding to fill it out and sign—click the button below to begin.
The Illinois Statutory Short Form Power of Attorney for Health Care represents a critical legal document that enables individuals to appoint an "agent" responsible for making crucial health care decisions on their behalf. Governed by the Illinois Power of Attorney Act, it underscores the importance of choosing a trustworthy and willing agent, given the broad powers including the consent, withdrawal, or refusal of medical treatment and hospital admission or discharge. Special emphasis is placed on the necessity of the agent acting in good faith and in accordance with the individual's wishes, possibly extending to end-of-life decisions. Furthermore, the form provides options for appointing successor agents, but explicitly prohibits the appointment of co-agents, ensuring a clear line of authority. It also details the agent's rights concerning the individual's medical records, the decision-making power post the principal's death especially concerning anatomical gifts, autopsy, and the disposition of remains, adhering to specific legal guidelines. The form's extensive nature allows for the specificity in limitations and conditions under which the powers are executed, ensuring the principal's healthcare preferences are respected. It remains effective throughout the individual's lifetime unless revoked, underscoring its significance in long-term healthcare planning. Understanding its comprehensive scope and potential implications is essential for anyone considering establishing a Power of Attorney for Health Care in Illinois.
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
Before starting the process of filling out the Illinois Short Form Power of Attorney for Health Care, understand that you are about to give another person significant authority over your health care decisions. This document enables them to make choices about your medical treatment, hospitalization, and even end-of-life care based on your preferences. Given the magnitude of responsibility you're entrusting to your designated agent, it’s crucial to select someone who understands your wishes and whom you trust implicitly. After ensuring you have comprehended the form's importance and implications, proceed to fill it out by following these steps:
Completing this form thoughtfully ensures that your health care decisions remain in trusted hands, even when you may not be able to make those decisions yourself. Remember, the choices you outline in this document should closely align with your health care preferences and values. After filling out the form, ensure that your agent, close family members, or friends, and your health care providers are aware of the document and understand your wishes.
Frequently Asked Questions about the Illinois Short Form Power of Attorney for Health Care
What is the Illinois Statutory Short Form Power of Attorney for Health Care?
This is a legal document that allows you, the principal, to appoint someone you trust, known as an "agent," to make health care decisions on your behalf should you become unable to do so. This includes decisions about treatment, admission to health care facilities, and end-of-life care.
Why is it important to create a Health Care Power of Attorney?
Creating this document ensures that someone who understands your wishes can make health care decisions for you, reflecting your desires and values, especially in situations where you cannot communicate them yourself.
Can I appoint more than one agent?
No, the Illinois form does not allow for co-agents. You can name a single individual as your agent and nominate successor agents if the primary agent is unable or unwilling to serve.
What powers does the agent have?
The agent can make a wide range of health care decisions on your behalf. This includes consenting to or refusing medical treatment, accessing your medical records, and making decisions about organ donation and the disposal of remains after death.
Is the agent's authority limited in any way?
Yes, you can impose specific limitations or rules on the agent's power in the form. For example, you can define your own conditions for when life-sustaining treatment should be withdrawn or refuse certain types of medical treatment.
When does the Power of Attorney become effective, and when does it end?
The document typically becomes effective upon signing, unless you specify otherwise, such as a determination of disability. It remains in effect until your death, unless you revoke it or specify an end date.
Can the Power of Attorney be revoked?
Yes, you can revoke this power of attorney at any time, provided you are competent. This can be done by informing your health care provider in writing or by creating a new power of attorney document.
What should I do after completing this document?
After signing the form, you should provide copies to your agent, successor agents, and health care providers. It's also a good idea to discuss your wishes and preferences with your agent to ensure they understand your desires clearly.
Filling out the Illinois Short Form Power of Attorney for Health Care can be daunting, and making errors can lead to unintended consequences. Here are nine common mistakes people often make:
By avoiding these errors, you can help ensure that your health care wishes are understood and respected in the event you cannot communicate them yourself.
When preparing for the future, especially regarding health care decisions, it's prudent to have a well-rounded set of legal documents in place. The Illinois Statutory Short Form Power of Attorney for Health Care is a critical document that allows you to designate someone to make health care decisions on your behalf if you're unable to do so. However, this form often works best when accompanied by other legal documents that provide a comprehensive approach to planning for the unexpected. Here's an overview of five additional forms and documents commonly used alongside the Illinois Short Form Power of Attorney for Health Care:
Each of these documents plays a vital role in ensuring your wishes are known and respected in various circumstances. They provide a clear directive to healthcare providers and relieve your loved ones from the burdensome task of making difficult decisions on your behalf without guidance. It's always advised to consult with a legal professional when drafting these documents to ensure they accurately reflect your wishes and are compliant with current Illinois laws.
Durable Power of Attorney for Asset Management: This document, similar to the Illinois Short Form Power of Attorney for Health Care, allows an individual to designate an agent to manage their financial affairs. Both documents involve appointing someone to make decisions on the principal's behalf, but the Durable Power of Attorney for Asset Management focuses on financial decisions rather than health care decisions.
Living Will: A Living Will is a document that outlines an individual's wishes regarding end-of-life care. Similar to the section in the Illinois form where the principal can specify preferences for life-sustaining treatment, a Living Will enables an individual to communicate their desires about the extent of medical treatment they want if they become unable to express those wishes themselves.
Advance Health Care Directive: This document combines the features of a Living Will and a Power of Attorney for Health Care. Like the Illinois Short Form, it allows individuals to appoint a health care agent and also specify their health care preferences. This ensures that the agent's decisions align with the principal's wishes regarding treatment options and end-of-life care.
General Power of Attorney: This grants broad powers to an agent to act on the principal's behalf in a variety of situations, not limited to health care. While similar to the Illinois Short Form in terms of appointing an agent, a General Power of Attorney covers a wider range of decisions beyond health care, including financial and legal decisions.
Do Not Resuscitate (DNR) Order: A DNR is a medical order that tells health care professionals not to perform CPR if a patient's breathing stops or if the heart stops beating. It is similar to directives within the Illinois Short Form that allow an individual to make choices about life-sustaining treatments. Both documents concern critical health care decisions although they serve different purposes.
MENTAL HEALTH Power of Attorney: This document specifically allows an individual to appoint an agent to make decisions regarding mental health care. It is similar to the Illinois Short Form because both empower an agent to make health-related decisions on the principal’s behalf. However, this type focuses exclusively on mental health.
Special or Limited Power of Attorney: Like the Illinois Short Form, this allows the principal to grant specific powers to an agent. While the Illinois Short Form focuses on health care decisions, a Special or Limited Power of Attorney can be tailored to a variety of specific tasks or situations, demonstrating the flexibility in assigning an agent for distinct purposes.
When filling out the Illinois Short Form Power of Attorney for Health Care, consider the following do's and don'ts to ensure your form is properly completed:
Following these guidelines will help ensure that the Illinois Statutory Short Form Power of Attorney for Health Care reflects your wishes and is legally valid.
When it comes to the Illinois Statutory Short Form Power of Attorney for Health Care, there are several misconceptions that need clarification to ensure individuals are fully informed about the legal and personal implications of signing this document. Understanding these nuances can empower individuals to make informed decisions regarding their health care and the delegation of decision-making authority.
Misconception 1: Once signed, the Power of Attorney cannot be revoked. Many people mistakenly believe that once the Power of Attorney for Health Care is signed, it is a final and irreversible action. However, the truth is that the principal (the person who signed the form) can revoke this Power at any time, provided they are competent to do so.
Misconception 2: The agent has immediate and total control over health decisions. Some individuals assume that as soon as the Power of Attorney for Health Care form is signed, the agent immediately gains control over all health care decisions for the principal. In reality, the agent's authority to make health care decisions only becomes active when the principal is unable to make those decisions themselves due to incapacity.
Misconception 3: The form grants power over financial matters. Another common misunderstanding is conflating the Health Care Power of Attorney with financial power of attorney. The Illinois Statutory Short Form Power of Attorney for Health Care is strictly limited to decisions about medical treatment and personal care; it does not give the agent any authority over financial or property matters.
Misconception 4: The agent’s decisions are final and cannot be contested. While the agent is granted broad powers to make health care decisions on the principal's behalf, their actions can be challenged in court if they are not acting in the principal's best interests, or if they are not adhering to the principal’s wishes as outlined in the Power of Attorney form or otherwise made known.
Misconception 5: The form cannot limit the agent's powers. It is commonly misbelieved that the powers granted to the agent are broad and cannot be limited. However, the principal can specify limitations or conditions on the agent's authority directly on the form, tailoring the agent’s powers to the principal’s personal wishes and values.
Misconception 6: The Power of Attorney for Health Care allows the agent to approve euthanasia. Illinois law does not permit euthanasia. The agent cannot make decisions that are outside the scope of legally accepted medical practices. The Powers granted include the ability to require, consent to, or withdraw treatment, including life-sustaining treatment, in accordance with the principal's wishes and state law, but do not extend to actions that are illegal.
Misconception 7: A notary public must notarize the Power of Attorney for it to be valid. While it's essential for the principal to sign the Power of Attorney for it to be effective, Illinois law does not require this type of document to be notarized. It must, however, be witnessed by a certain number of adults who meet specific criteria outlined in the law.
Understanding these key points about the Illinois Statutory Short Form Power of Attorney for Health Care allows individuals to make informed decisions that best reflect their health care wishes and ensure that their rights are protected.
The Illinois Short Form Power of Attorney (POA) for Health Care is a legal document that allows you to appoint someone, referred to as an "agent," to make health care decisions on your behalf if you are unable to make those decisions yourself. Here are some key takeaways about filling out and using this form:
Educating yourself about the contents and implications of this form is crucial before signing it. Consulting with a lawyer can help clarify any parts of the document that are unclear and ensure that it accurately reflects your wishes regarding your health care.
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