SB1877 EnrolledLRB097 09886 AJO 50046 b

1    AN ACT concerning civil law.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Power of Attorney Act is amended by
5changing Section 4-10 as follows:
 
6    (755 ILCS 45/4-10)  (from Ch. 110 1/2, par. 804-10)
7    (Text of Section before amendment by P.A. 96-1195)
8    Sec. 4-10. Statutory short form power of attorney for
9health care.
10    (a) The following form (sometimes also referred to in this
11Act as the "statutory health care power") may be used to grant
12an agent powers with respect to the principal's own health
13care; but the statutory health care power is not intended to be
14exclusive nor to cover delegation of a parent's power to
15control the health care of a minor child, and no provision of
16this Article shall be construed to invalidate or bar use by the
17principal of any other or different form of power of attorney
18for health care. Nonstatutory health care powers must be
19executed by the principal, designate the agent and the agent's
20powers, and comply with Section 4-5 of this Article, but they
21need not be witnessed or conform in any other respect to the
22statutory health care power. When a power of attorney in
23substantially the following form is used, including the

 

 

SB1877 Enrolled- 2 -LRB097 09886 AJO 50046 b

1"notice" paragraph at the beginning in capital letters, it
2shall have the meaning and effect prescribed in this Act. The
3statutory health care power may be included in or combined with
4any other form of power of attorney governing property or other
5matters.
6    "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH
7CARE
8    (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE
9THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE
10HEALTH CARE DECISIONS FOR YOU, INCLUDING POWER TO REQUIRE,
11CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL
12TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT YOU
13TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER
14INSTITUTION. THIS FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO
15EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE EXERCISED, YOUR
16AGENT WILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN
17ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF RECEIPTS,
18DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT
19CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS
20NOT ACTING PROPERLY. YOU MAY NAME SUCCESSOR AGENTS UNDER THIS
21FORM BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE
22NAMED. UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN
23THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A
24COURT ACTING ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY
25EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN
26AFTER YOU BECOME DISABLED. THE POWERS YOU GIVE YOUR AGENT, YOUR

 

 

SB1877 Enrolled- 3 -LRB097 09886 AJO 50046 b

1RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR VIOLATING
2THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND
34-10(b) OF THE ILLINOIS "POWERS OF ATTORNEY FOR HEALTH CARE
4LAW" OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM).
5THAT LAW EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF
6POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS ANYTHING ABOUT
7THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER
8TO EXPLAIN IT TO YOU.)
9    POWER OF ATTORNEY made this .......................day of
10................................
11    (month)  (year)
12    1. I, ..................................................,
13              (insert name and address of principal)
14hereby appoint:
15............................................................
16          (insert name and address of agent)
17as my attorney-in-fact (my "agent") to act for me and in my
18name (in any way I could act in person) to make any and all
19decisions for me concerning my personal care, medical
20treatment, hospitalization and health care and to require,
21withhold or withdraw any type of medical treatment or
22procedure, even though my death may ensue. My agent shall have
23the same access to my medical records that I have, including
24the right to disclose the contents to others. My agent shall
25also have full power to authorize an autopsy and direct the
26disposition of my remains. Effective upon my death, my agent

 

 

SB1877 Enrolled- 4 -LRB097 09886 AJO 50046 b

1has the full power to make an anatomical gift of the following
2(initial one):
3        ....Any organs, tissues, or eyes suitable for
4    transplantation or used for research or education.
5        ....Specific organs:.................................
6(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS
7POSSIBLE SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY
8DECISION YOU COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF
9HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD AND WATER AND OTHER
10LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH ACTION
11WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU WISH
12TO LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE SPECIAL
13RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE
14AUTOPSY OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE FOLLOWING
15PARAGRAPHS.)
16    2. The powers granted above shall not include the following
17powers or shall be subject to the following rules or
18limitations (here you may include any specific limitations you
19deem appropriate, such as: your own definition of when
20life-sustaining measures should be withheld; a direction to
21continue food and fluids or life-sustaining treatment in all
22events; or instructions to refuse any specific types of
23treatment that are inconsistent with your religious beliefs or
24unacceptable to you for any other reason, such as blood
25transfusion, electro-convulsive therapy, amputation,
26psychosurgery, voluntary admission to a mental institution,

 

 

SB1877 Enrolled- 5 -LRB097 09886 AJO 50046 b

1etc.):
2.............................................................
3.............................................................
4.............................................................
5.............................................................
6.............................................................
7(THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR
8IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT,
9SOME GENERAL STATEMENTS CONCERNING THE WITHHOLDING OR REMOVAL
10OF LIFE-SUSTAINING TREATMENT ARE SET FORTH BELOW. IF YOU AGREE
11WITH ONE OF THESE STATEMENTS, YOU MAY INITIAL THAT STATEMENT;
12BUT DO NOT INITIAL MORE THAN ONE):
13    I do not want my life to be prolonged nor do I want
14life-sustaining treatment to be provided or continued if my
15agent believes the burdens of the treatment outweigh the
16expected benefits. I want my agent to consider the relief of
17suffering, the expense involved and the quality as well as the
18possible extension of my life in making decisions concerning
19life-sustaining treatment.
20
Initialed...........................
21    I want my life to be prolonged and I want life-sustaining
22treatment to be provided or continued unless I am in a coma
23which my attending physician believes to be irreversible, in
24accordance with reasonable medical standards at the time of
25reference. If and when I have suffered irreversible coma, I
26want life-sustaining treatment to be withheld or discontinued.

 

 

SB1877 Enrolled- 6 -LRB097 09886 AJO 50046 b

1
Initialed...........................
2    I want my life to be prolonged to the greatest extent
3possible without regard to my condition, the chances I have for
4recovery or the cost of the procedures.
5
Initialed...........................
6(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE
7MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF
8ATTORNEY FOR HEALTH CARE LAW" (SEE THE BACK OF THIS FORM).
9ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS
10POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER
11IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF
12ANATOMICAL GIFT, AUTOPSY OR DISPOSITION OF REMAINS IS
13AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR
14DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF
15THE FOLLOWING:)
16    3.  ( ) This power of attorney shall become effective on
17.............................................................
18.............................................................
19(insert a future date or event during your lifetime, such as
20court determination of your disability, when you want this
21power to first take effect)
22    4.  ( ) This power of attorney shall terminate on .......
23.............................................................
24(insert a future date or event, such as court determination of
25your disability, when you want this power to terminate prior to
26your death)

 

 

SB1877 Enrolled- 7 -LRB097 09886 AJO 50046 b

1(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND
2ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)
3    5. If any agent named by me shall die, become incompetent,
4resign, refuse to accept the office of agent or be unavailable,
5I name the following (each to act alone and successively, in
6the order named) as successors to such agent:
7.............................................................
8.............................................................
9For purposes of this paragraph 5, a person shall be considered
10to be incompetent if and while the person is a minor or an
11adjudicated incompetent or disabled person or the person is
12unable to give prompt and intelligent consideration to health
13care matters, as certified by a licensed physician. (IF YOU
14WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, IN THE
15EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU MAY,
16BUT ARE NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING
17PARAGRAPH. THE COURT WILL APPOINT YOUR AGENT IF THE COURT FINDS
18THAT SUCH APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND
19WELFARE. STRIKE OUT PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT
20TO ACT AS GUARDIAN.)
21    6. If a guardian of my person is to be appointed, I
22nominate the agent acting under this power of attorney as such
23guardian, to serve without bond or security.
24    7. I am fully informed as to all the contents of this form
25and understand the full import of this grant of powers to my
26agent.

 

 

SB1877 Enrolled- 8 -LRB097 09886 AJO 50046 b

1
Signed..............................
2
(principal)
      
3    The principal has had an opportunity to read the above form
4and has signed the form or acknowledged his or her signature or
5mark on the form in my presence.
6..........................  Residing at......................
7        (witness)
8(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND
9SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU
10INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST
11COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE
12AGENTS.)
13Specimen signatures of    I certify that the signatures of my
14agent (and successors).   agent (and successors) are correct.
15.......................   ...................................
16       (agent)                      (principal)
17.......................   ...................................
18   (successor agent)                (principal)
19.......................   ...................................
20   (successor agent)                (principal)"
21    (b) The statutory short form power of attorney for health
22care (the "statutory health care power") authorizes the agent
23to make any and all health care decisions on behalf of the
24principal which the principal could make if present and under
25no disability, subject to any limitations on the granted powers
26that appear on the face of the form, to be exercised in such

 

 

SB1877 Enrolled- 9 -LRB097 09886 AJO 50046 b

1manner as the agent deems consistent with the intent and
2desires of the principal. The agent will be under no duty to
3exercise granted powers or to assume control of or
4responsibility for the principal's health care; but when
5granted powers are exercised, the agent will be required to use
6due care to act for the benefit of the principal in accordance
7with the terms of the statutory health care power and will be
8liable for negligent exercise. The agent may act in person or
9through others reasonably employed by the agent for that
10purpose but may not delegate authority to make health care
11decisions. The agent may sign and deliver all instruments,
12negotiate and enter into all agreements and do all other acts
13reasonably necessary to implement the exercise of the powers
14granted to the agent. Without limiting the generality of the
15foregoing, the statutory health care power shall include the
16following powers, subject to any limitations appearing on the
17face of the form:
18        (1) The agent is authorized to give consent to and
19    authorize or refuse, or to withhold or withdraw consent to,
20    any and all types of medical care, treatment or procedures
21    relating to the physical or mental health of the principal,
22    including any medication program, surgical procedures,
23    life-sustaining treatment or provision of food and fluids
24    for the principal.
25        (2) The agent is authorized to admit the principal to
26    or discharge the principal from any and all types of

 

 

SB1877 Enrolled- 10 -LRB097 09886 AJO 50046 b

1    hospitals, institutions, homes, residential or nursing
2    facilities, treatment centers and other health care
3    institutions providing personal care or treatment for any
4    type of physical or mental condition. The agent shall have
5    the same right to visit the principal in the hospital or
6    other institution as is granted to a spouse or adult child
7    of the principal, any rule of the institution to the
8    contrary notwithstanding.
9        (3) The agent is authorized to contract for any and all
10    types of health care services and facilities in the name of
11    and on behalf of the principal and to bind the principal to
12    pay for all such services and facilities, and to have and
13    exercise those powers over the principal's property as are
14    authorized under the statutory property power, to the
15    extent the agent deems necessary to pay health care costs;
16    and the agent shall not be personally liable for any
17    services or care contracted for on behalf of the principal.
18        (4) At the principal's expense and subject to
19    reasonable rules of the health care provider to prevent
20    disruption of the principal's health care, the agent shall
21    have the same right the principal has to examine and copy
22    and consent to disclosure of all the principal's medical
23    records that the agent deems relevant to the exercise of
24    the agent's powers, whether the records relate to mental
25    health or any other medical condition and whether they are
26    in the possession of or maintained by any physician,

 

 

SB1877 Enrolled- 11 -LRB097 09886 AJO 50046 b

1    psychiatrist, psychologist, therapist, hospital, nursing
2    home or other health care provider.
3        (5) The agent is authorized: to direct that an autopsy
4    be made pursuant to Section 2 of "An Act in relation to
5    autopsy of dead bodies", approved August 13, 1965,
6    including all amendments; to make a disposition of any part
7    or all of the principal's body pursuant to the Illinois
8    Anatomical Gift Act, as now or hereafter amended; and to
9    direct the disposition of the principal's remains.
10(Source: P.A. 93-794, eff. 7-22-04.)
 
11    (Text of Section after amendment by P.A. 96-1195)
12    Sec. 4-10. Statutory short form power of attorney for
13health care.
14    (a) The form prescribed in this Section (sometimes also
15referred to in this Act as the "statutory health care power")
16may be used to grant an agent powers with respect to the
17principal's own health care; but the statutory health care
18power is not intended to be exclusive nor to cover delegation
19of a parent's power to control the health care of a minor
20child, and no provision of this Article shall be construed to
21invalidate or bar use by the principal of any other or
22different form of power of attorney for health care.
23Nonstatutory health care powers must be executed by the
24principal, designate the agent and the agent's powers, and
25comply with Section 4-5 of this Article, but they need not be

 

 

SB1877 Enrolled- 12 -LRB097 09886 AJO 50046 b

1witnessed or conform in any other respect to the statutory
2health care power. When a power of attorney in substantially
3the form prescribed in this Section is used, including the
4"Notice to the Individual Signing the Illinois Statutory Short
5Form Power of Attorney for Health Care" (or "Notice"
6paragraphs) at the beginning of the form on a separate sheet in
714-point type, it shall have the meaning and effect prescribed
8in this Act. A power of attorney for health care shall be
9deemed to be in substantially the same format as the statutory
10form if the explanatory language throughout the form (the
11language following the designation "NOTE:") is distinguished
12in some way from the legal paragraphs in the form, such as the
13use of boldface or other difference in typeface and font or
14point size, even if the "Notice" paragraphs at the beginning
15are not on a separate sheet of paper or are not in 14-point
16type, or if the principal's initials do not appear in the
17acknowledgement at the end of the "Notice" paragraphs. The
18statutory health care power may be included in or combined with
19any other form of power of attorney governing property or other
20matters.
21    (b) The Illinois Statutory Short Form Power of Attorney for
22Health Care shall be substantially as follows:
 
23
"NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS
24
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE

 

 

 

SB1877 Enrolled- 13 -LRB097 09886 AJO 50046 b

1    PLEASE READ THIS NOTICE CAREFULLY. The form that you will
2be signing is a legal document. It is governed by the Illinois
3Power of Attorney Act. If there is anything about this form
4that you do not understand, you should ask a lawyer to explain
5it to you.
6    The purpose of this Power of Attorney is to give your
7designated "agent" broad powers to make health care decisions
8for you, including the power to require, consent to, or
9withdraw treatment for any physical or mental condition, and to
10admit you or discharge you from any hospital, home, or other
11institution. You may name successor agents under this form, but
12you may not name co-agents.
13    This form does not impose a duty upon your agent to make
14such health care decisions, so it is important that you select
15an agent who will agree to do this for you and who will make
16those decisions as you would wish. It is also important to
17select an agent whom you trust, since you are giving that agent
18control over your medical decision-making, including
19end-of-life decisions. Any agent who does act for you has a
20duty to act in good faith for your benefit and to use due care,
21competence, and diligence. He or she must also act in
22accordance with the law and with the statements in this form.
23Your agent must keep a record of all significant actions taken
24as your agent.
25    Unless you specifically limit the period of time that this
26Power of Attorney will be in effect, your agent may exercise

 

 

SB1877 Enrolled- 14 -LRB097 09886 AJO 50046 b

1the powers given to him or her throughout your lifetime, even
2after you become disabled. A court, however, can take away the
3powers of your agent if it finds that the agent is not acting
4properly. You may also revoke this Power of Attorney if you
5wish.
6    The Powers you give your agent, your right to revoke those
7powers, and the penalties for violating the law are explained
8more fully in Sections 4-5, 4-6, and 4-10(c) 4-10(b) of the
9Illinois Power of Attorney Act. This form is a part of that
10law. The "NOTE" paragraphs throughout this form are
11instructions.
12    You are not required to sign this Power of Attorney, but it
13will not take effect without your signature. You should not
14sign it if you do not understand everything in it, and what
15your agent will be able to do if you do sign it.
 
16    Please put your initials on the following line indicating
17that you have read this Notice:
18
......................
19
(Principal's initials)"

 
20
"ILLINOIS STATUTORY SHORT FORM
21
POWER OF ATTORNEY FOR HEALTH CARE

 
22    1. I, ..................................................,
23(insert name and address of principal) hereby revoke all prior

 

 

SB1877 Enrolled- 15 -LRB097 09886 AJO 50046 b

1powers of attorney for health care executed by me and appoint:
2............................................................
3(insert name and address of agent)
4(NOTE: You may not name co-agents using this form.)
5as my attorney-in-fact (my "agent") to act for me and in my
6name (in any way I could act in person) to make any and all
7decisions for me concerning my personal care, medical
8treatment, hospitalization and health care and to require,
9withhold or withdraw any type of medical treatment or
10procedure, even though my death may ensue.
11    A. My agent shall have the same access to my medical
12records that I have, including the right to disclose the
13contents to others.
14    B. Effective upon my death, my agent has the full power to
15make an anatomical gift of the following:
16(NOTE: Initial one. In the event none of the options are
17initialed, then it shall be concluded that you do not wish to
18grant your agent any such authority.)
19        .... Any organs, tissues, or eyes suitable for
20    transplantation or used for research or education.
21        .... Specific organs:................................
22        .... I do not grant my agent authority to make any
23    anatomical gifts.
24    C. My agent shall also have full power to authorize an
25autopsy and direct the disposition of my remains. I intend for
26this power of attorney to be in substantial compliance with

 

 

SB1877 Enrolled- 16 -LRB097 09886 AJO 50046 b

1Section 10 of the Disposition of Remains Act. All decisions
2made by my agent with respect to the disposition of my remains,
3including cremation, shall be binding. I hereby direct any
4cemetery organization, business operating a crematory or
5columbarium or both, funeral director or embalmer, or funeral
6establishment who receives a copy of this document to act under
7it.
8    D. I intend for the person named as my agent to be treated
9as I would be with respect to my rights regarding the use and
10disclosure of my individually identifiable health information
11or other medical records, including records or communications
12governed by the Mental Health and Developmental Disabilities
13Confidentiality Act. This release authority applies to any
14information governed by the Health Insurance Portability and
15Accountability Act of 1996 ("HIPAA") and regulations
16thereunder. I intend for the person named as my agent to serve
17as my "personal representative" as that term is defined under
18HIPAA and regulations thereunder.
19    (i) The person named as my agent shall have the power to
20authorize the release of information governed by HIPAA to third
21parties.
22    (ii) I authorize any physician, health care professional,
23dentist, health plan, hospital, clinic, laboratory, pharmacy
24or other covered health care provider, any insurance company
25and the Medical Informational Bureau, Inc., or any other health
26care clearinghouse that has provided treatment or services to

 

 

SB1877 Enrolled- 17 -LRB097 09886 AJO 50046 b

1me, or that has paid for or is seeking payment for me for such
2services to give, disclose, and release to the person named as
3my agent, without restriction, all of my individually
4identifiable health information and medical records, regarding
5any past, present, or future medical or mental health
6condition, including all information relating to the diagnosis
7and treatment of HIV/AIDS, sexually transmitted diseases, drug
8or alcohol abuse, and mental illness (including records or
9communications governed by the Mental Health and Developmental
10Disabilities Confidentiality Act).
11    (iii) The authority given to the person named as my agent
12shall supersede any prior agreement that I may have with my
13health care providers to restrict access to, or disclosure of,
14my individually identifiable health information. The authority
15given to the person named as my agent has no expiration date
16and shall expire only in the event that I revoke the authority
17in writing and deliver it to my health care provider. The
18authority given to the person named as my agent to serve as my
19"personal representative" as defined under HIPAA and
20regulations thereunder and to access my individually
21identifiable health information or authorize the release of the
22same to third parties shall take effect immediately, even if I
23designate in Paragraph 3 of this document that this agency
24shall otherwise take effect at some future date.
25(NOTE: The above grant of power is intended to be as broad as
26possible so that your agent will have the authority to make any

 

 

SB1877 Enrolled- 18 -LRB097 09886 AJO 50046 b

1decision you could make to obtain or terminate any type of
2health care, including withdrawal of food and water and other
3life-sustaining measures, if your agent believes such action
4would be consistent with your intent and desires. If you wish
5to limit the scope of your agent's powers or prescribe special
6rules or limit the power to make an anatomical gift, authorize
7autopsy or dispose of remains, you may do so in the following
8paragraphs.)
9    2. The powers granted above shall not include the following
10powers or shall be subject to the following rules or
11limitations:
12(NOTE: Here you may include any specific limitations you deem
13appropriate, such as: your own definition of when
14life-sustaining measures should be withheld; a direction to
15continue food and fluids or life-sustaining treatment in all
16events; or instructions to refuse any specific types of
17treatment that are inconsistent with your religious beliefs or
18unacceptable to you for any other reason, such as blood
19transfusion, electro-convulsive therapy, amputation,
20psychosurgery, voluntary admission to a mental institution,
21etc.)
22.............................................................
23.............................................................
24.............................................................
25.............................................................
26.............................................................

 

 

SB1877 Enrolled- 19 -LRB097 09886 AJO 50046 b

1(NOTE: The subject of life-sustaining treatment is of
2particular importance. For your convenience in dealing with
3that subject, some general statements concerning the
4withholding or removal of life-sustaining treatment are set
5forth below. If you agree with one of these statements, you may
6initial that statement; but do not initial more than one. These
7statements serve as guidance for your agent, who shall give
8careful consideration to the statement you initial when
9engaging in health care decision-making on your behalf.)
10    I do not want my life to be prolonged nor do I want
11life-sustaining treatment to be provided or continued if my
12agent believes the burdens of the treatment outweigh the
13expected benefits. I want my agent to consider the relief of
14suffering, the expense involved and the quality as well as the
15possible extension of my life in making decisions concerning
16life-sustaining treatment.
17
Initialed ...........................
18    I want my life to be prolonged and I want life-sustaining
19treatment to be provided or continued, unless I am, in the
20opinion of my attending physician, in accordance with
21reasonable medical standards at the time of reference, in a
22state of "permanent unconsciousness" or suffer from an
23"incurable or irreversible condition" or "terminal condition",
24as those terms are defined in Section 4-4 of the Illinois Power
25of Attorney Act. If and when I am in any one of these states or
26conditions, I want life-sustaining treatment to be withheld or

 

 

SB1877 Enrolled- 20 -LRB097 09886 AJO 50046 b

1discontinued.
2
Initialed ...........................
3    I want my life to be prolonged to the greatest extent
4possible in accordance with reasonable medical standards
5without regard to my condition, the chances I have for recovery
6or the cost of the procedures.
7
Initialed ...........................
8(NOTE: This power of attorney may be amended or revoked by you
9in the manner provided in Section 4-6 of the Illinois Power of
10Attorney Act. Your agent can act immediately, unless you
11specify otherwise; but you cannot specify otherwise with
12respect to your "personal representative" under subparagraph
13D(iii).)
14    3.   This power of attorney shall become effective on
15.............................................................
16.............................................................
17(NOTE: Insert a future date or event during your lifetime, such
18as a court determination of your disability or a written
19determination by your physician that you are incapacitated,
20when you want this power to first take effect.)
21(NOTE: If you do not amend or revoke this power, or if you do
22not specify a specific ending date in paragraph 4, it will
23remain in effect until your death; except that your agent will
24still have the authority to donate your organs, authorize an
25autopsy, and dispose of your remains after your death, if you
26grant that authority to your agent.)

 

 

SB1877 Enrolled- 21 -LRB097 09886 AJO 50046 b

1    4.   This power of attorney shall terminate on ..........
2.............................................................
3(NOTE: Insert a future date or event, such as a court
4determination that you are not under a legal disability or a
5written determination by your physician that you are not
6incapacitated, if you want this power to terminate prior to
7your death.)
8(NOTE: You cannot use this form to name co-agents. If you wish
9to name successor agents, insert the names and addresses of the
10successors in paragraph 5.)
11    5. If any agent named by me shall die, become incompetent,
12resign, refuse to accept the office of agent or be unavailable,
13I name the following (each to act alone and successively, in
14the order named) as successors to such agent:
15.............................................................
16.............................................................
17For purposes of this paragraph 5, a person shall be considered
18to be incompetent if and while the person is a minor, or an
19adjudicated incompetent or disabled person, or the person is
20unable to give prompt and intelligent consideration to health
21care matters, as certified by a licensed physician.
22(NOTE: If you wish to, you may name your agent as guardian of
23your person if a court decides that one should be appointed. To
24do this, retain paragraph 6, and the court will appoint your
25agent if the court finds that this appointment will serve your
26best interests and welfare. Strike out paragraph 6 if you do

 

 

SB1877 Enrolled- 22 -LRB097 09886 AJO 50046 b

1not want your agent to act as guardian.)
2    6. If a guardian of my person is to be appointed, I
3nominate the agent acting under this power of attorney as such
4guardian, to serve without bond or security.
5    7. I am fully informed as to all the contents of this form
6and understand the full import of this grant of powers to my
7agent.
8Dated: .......... 
9
Signed ..............................
10
(principal's signature or mark)
  
 
11    The principal has had an opportunity to review the above
12form and has signed the form or acknowledged his or her
13signature or mark on the form in my presence. The undersigned
14witness certifies that the witness is not: (a) the attending
15physician or mental health service provider or a relative of
16the physician or provider; (b) an owner, operator, or relative
17of an owner or operator of a health care facility in which the
18principal is a patient or resident; (c) a parent, sibling,
19descendant, or any spouse of such parent, sibling, or
20descendant of either the principal or any agent or successor
21agent under the foregoing power of attorney, whether such
22relationship is by blood, marriage, or adoption; or (d) an
23agent or successor agent under the foregoing power of attorney.
24
.......................
25
(Witness Signature)

 

 

SB1877 Enrolled- 23 -LRB097 09886 AJO 50046 b

1
.......................
2
(Print Witness Name)
3
.......................
4
(Street Address)
5
.......................
6
(City, State, ZIP)
7(NOTE: You may, but are not required to, request your agent and
8successor agents to provide specimen signatures below. If you
9include specimen signatures in this power of attorney, you must
10complete the certification opposite the signatures of the
11agents.)
12Specimen signatures of    I certify that the signatures of my
13agent (and successors).   agent (and successors) are correct.
14.......................   ...................................
15       (agent)                      (principal)
16.......................   ...................................
17   (successor agent)                (principal)
18.......................   ...................................
19   (successor agent)                (principal)"
 
20    (NOTE: The name, address, and phone number of the person
21preparing this form or who assisted the principal in completing
22this form is optional.)
23
.........................
24
(name of preparer)
25
.........................

 

 

SB1877 Enrolled- 24 -LRB097 09886 AJO 50046 b

1
.........................
2
(address)
3
.........................
4
(phone)
5    (c) The statutory short form power of attorney for health
6care (the "statutory health care power") authorizes the agent
7to make any and all health care decisions on behalf of the
8principal which the principal could make if present and under
9no disability, subject to any limitations on the granted powers
10that appear on the face of the form, to be exercised in such
11manner as the agent deems consistent with the intent and
12desires of the principal. The agent will be under no duty to
13exercise granted powers or to assume control of or
14responsibility for the principal's health care; but when
15granted powers are exercised, the agent will be required to use
16due care to act for the benefit of the principal in accordance
17with the terms of the statutory health care power and will be
18liable for negligent exercise. The agent may act in person or
19through others reasonably employed by the agent for that
20purpose but may not delegate authority to make health care
21decisions. The agent may sign and deliver all instruments,
22negotiate and enter into all agreements and do all other acts
23reasonably necessary to implement the exercise of the powers
24granted to the agent. Without limiting the generality of the
25foregoing, the statutory health care power shall include the
26following powers, subject to any limitations appearing on the

 

 

SB1877 Enrolled- 25 -LRB097 09886 AJO 50046 b

1face of the form:
2        (1) The agent is authorized to give consent to and
3    authorize or refuse, or to withhold or withdraw consent to,
4    any and all types of medical care, treatment or procedures
5    relating to the physical or mental health of the principal,
6    including any medication program, surgical procedures,
7    life-sustaining treatment or provision of food and fluids
8    for the principal.
9        (2) The agent is authorized to admit the principal to
10    or discharge the principal from any and all types of
11    hospitals, institutions, homes, residential or nursing
12    facilities, treatment centers and other health care
13    institutions providing personal care or treatment for any
14    type of physical or mental condition. The agent shall have
15    the same right to visit the principal in the hospital or
16    other institution as is granted to a spouse or adult child
17    of the principal, any rule of the institution to the
18    contrary notwithstanding.
19        (3) The agent is authorized to contract for any and all
20    types of health care services and facilities in the name of
21    and on behalf of the principal and to bind the principal to
22    pay for all such services and facilities, and to have and
23    exercise those powers over the principal's property as are
24    authorized under the statutory property power, to the
25    extent the agent deems necessary to pay health care costs;
26    and the agent shall not be personally liable for any

 

 

SB1877 Enrolled- 26 -LRB097 09886 AJO 50046 b

1    services or care contracted for on behalf of the principal.
2        (4) At the principal's expense and subject to
3    reasonable rules of the health care provider to prevent
4    disruption of the principal's health care, the agent shall
5    have the same right the principal has to examine and copy
6    and consent to disclosure of all the principal's medical
7    records that the agent deems relevant to the exercise of
8    the agent's powers, whether the records relate to mental
9    health or any other medical condition and whether they are
10    in the possession of or maintained by any physician,
11    psychiatrist, psychologist, therapist, hospital, nursing
12    home or other health care provider.
13        (5) The agent is authorized: to direct that an autopsy
14    be made pursuant to Section 2 of "An Act in relation to
15    autopsy of dead bodies", approved August 13, 1965,
16    including all amendments; to make a disposition of any part
17    or all of the principal's body pursuant to the Illinois
18    Anatomical Gift Act, as now or hereafter amended; and to
19    direct the disposition of the principal's remains.
20(Source: P.A. 96-1195, eff. 7-1-11.)
 
21    Section 99. Effective date. This Act takes effect July 1,
222011.