Bill Text: IL SB1877 | 2011-2012 | 97th General Assembly | Chaptered

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Bill Title: Amends the Illinois Power of Attorney Act. Changes a reference to the Act in the statutory short form power of attorney for health care. Effective immediately.

Spectrum: Slight Partisan Bill (Republican 2-1)

Status: (Passed) 2011-07-14 - Public Act . . . . . . . . . 97-0148 [SB1877 Detail]

Download: Illinois-2011-SB1877-Chaptered.html

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Public Act 097-0148
SB1877 Enrolled LRB097 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.