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Full Text of SB3228  98th General Assembly




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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 Sections 4-4, 4-5, 4-5.1, 4-10, and 4-12 as follows:
6    (755 ILCS 45/4-4)  (from Ch. 110 1/2, par. 804-4)
7    Sec. 4-4. Definitions. As used in this Article:
8    (a) "Attending physician" means the physician who has
9primary responsibility at the time of reference for the
10treatment and care of the patient.
11    (b) "Health care" means any care, treatment, service or
12procedure to maintain, diagnose, treat or provide for the
13patient's physical or mental health or personal care.
14    (c) "Health care agency" means an agency governing any type
15of health care, anatomical gift, autopsy or disposition of
16remains for and on behalf of a patient and refers to the power
17of attorney or other written instrument defining the agency or
18the agency, itself, as appropriate to the context.
19    (d) "Health care provider", "health care professional", or
20"provider" means the attending physician and any other person
21administering health care to the patient at the time of
22reference who is licensed, certified, or otherwise authorized
23or permitted by law to administer health care in the ordinary



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1course of business or the practice of a profession, including
2any person employed by or acting for any such authorized
4    (e) "Patient" means the principal or, if the agency governs
5health care for a minor child of the principal, then the child.
6    (e-5) "Health care agent" means an individual at least 18
7years old designated by the principal to make health care
8decisions of any type, including, but not limited to,
9anatomical gift, autopsy, or disposition of remains for and on
10behalf of the individual. A health care agent is a personal
11representative under state and federal law. The health care
12agent has the authority of a personal representative under both
13state and federal law unless restricted specifically by the
14health care agency.
15    (f) (Blank). "Incurable or irreversible condition" means
16an illness or injury (i) for which there is no reasonable
17prospect of cure or recovery, (ii) that ultimately will cause
18the patient's death even if life-sustaining treatment is
19initiated or continued, (iii) that imposes severe pain or
20otherwise imposes an inhumane burden on the patient, or (iv)
21for which initiating or continuing life-sustaining treatment,
22in light of the patient's medical condition, provides only
23minimal medical benefit.
24    (g) (Blank). "Permanent unconsciousness" means a condition
25that, to a high degree of medical certainty, (i) will last
26permanently, without improvement, (ii) in which thought,



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1sensation, purposeful action, social interaction, and
2awareness of self and environment are absent, and (iii) for
3which initiating or continuing life-sustaining treatment, in
4light of the patient's medical condition, provides only minimal
5medical benefit. For the purposes of this definition, "medical
6benefit" means a chance to cure or reverse a condition.
7    (h) (Blank). "Terminal condition" means an illness or
8injury for which there is no reasonable prospect of cure or
9recovery, death is imminent, and the application of
10life-sustaining treatment would only prolong the dying
12(Source: P.A. 96-1195, eff. 7-1-11.)
13    (755 ILCS 45/4-5)  (from Ch. 110 1/2, par. 804-5)
14    Sec. 4-5. Limitations on health care agencies. Neither the
15attending physician nor any other health care provider or
16health care professional may act as agent under a health care
17agency; however, a person who is not administering health care
18to the patient may act as health care agent for the patient
19even though the person is a physician or otherwise licensed,
20certified, authorized, or permitted by law to administer health
21care in the ordinary course of business or the practice of a
23(Source: P.A. 86-736.)
24    (755 ILCS 45/4-5.1)



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1    Sec. 4-5.1. Limitations on who may witness health care
3    (a) Every health care agency shall bear the signature of a
4witness to the signing of the agency. No witness may be under
518 years of age. None of the following licensed professionals
6providing services to the principal may serve as a witness to
7the signing of a health care agency:
8        (1) the attending physician, advanced practice nurse,
9    physician assistant, dentist, podiatric physician,
10    optometrist, or mental health service provider of the
11    principal, or a relative of the physician, advanced
12    practice nurse, physician assistant, dentist, podiatric
13    physician, optometrist, or mental health service provider;
14        (2) an owner, operator, or relative of an owner or
15    operator of a health care facility in which the principal
16    is a patient or resident;
17        (3) a parent, sibling, or descendant, or the spouse of
18    a parent, sibling, or descendant, of either the principal
19    or any agent or successor agent, regardless of whether the
20    relationship is by blood, marriage, or adoption;
21        (4) an agent or successor agent for health care.
22    (b) The prohibition on the operator of a health care
23facility from serving as a witness shall extend to directors
24and executive officers of an operator that is a corporate
25entity but not other employees of the operator such as, but not
26limited to, non-owner chaplains or social workers, nurses, and



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1other employees.
2(Source: P.A. 96-1195, eff. 7-1-11.)
3    (755 ILCS 45/4-10)  (from Ch. 110 1/2, par. 804-10)
4    Sec. 4-10. Statutory short form power of attorney for
5health care.
6    (a) The form prescribed in this Section (sometimes also
7referred to in this Act as the "statutory health care power")
8may be used to grant an agent powers with respect to the
9principal's own health care; but the statutory health care
10power is not intended to be exclusive nor to cover delegation
11of a parent's power to control the health care of a minor
12child, and no provision of this Article shall be construed to
13invalidate or bar use by the principal of any other or
14different form of power of attorney for health care.
15Nonstatutory health care powers must be executed by the
16principal, designate the agent and the agent's powers, and
17comply with the limitations in Section 4-5 of this Article, but
18they need not be witnessed or conform in any other respect to
19the statutory health care power.
20    No specific format is required for the statutory health
21care power of attorney other than the notice must precede the
22form. When a power of attorney in substantially the form
23prescribed in this Section is used, including the "Notice to
24the Individual Signing the Illinois Statutory Short Form Power
25of Attorney for Health Care" (or "Notice" paragraphs) at the



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1beginning of the form on a separate sheet in 14-point type, it
2shall have the meaning and effect prescribed in this Act. A
3power of attorney for health care shall be deemed to be in
4substantially the same format as the statutory form if the
5explanatory language throughout the form (the language
6following the designation "NOTE:") is distinguished in some way
7from the legal paragraphs in the form, such as the use of
8boldface or other difference in typeface and font or point
9size, even if the "Notice" paragraphs at the beginning are not
10on a separate sheet of paper or are not in 14-point type, or if
11the principal's initials do not appear in the acknowledgement
12at the end of the "Notice" paragraphs. The statutory health
13care power may be included in or combined with any other form
14of power of attorney governing property or other matters.
15    (b) The Illinois Statutory Short Form Power of Attorney for
16Health Care shall be substantially as follows:
19    No one can predict when a serious illness or accident might
20occur. When it does, you may need someone else to speak or make
21health care decisions for you. If you plan now, you can
22increase the chances that the medical treatment you get will be
23the treatment you want.
24    In Illinois, you can choose someone to be your "health care
25agent". Your agent is the person you trust to make health care



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1decisions for you if you are unable or do not want to make them
2yourself. These decisions should be based on your personal
3values and wishes.
4    It is important to put your choice of agent in writing. The
5written form is often called an "advance directive". You may
6use this form or another form, as long as it meets the legal
7requirements of Illinois. There are many written and on-line
8resources to guide you and your loved ones in having a
9conversation about these issues. You may find it helpful to
10look at these resources while thinking about and discussing
11your advance directive.
14    The selection of your agent should be considered carefully,
15as your agent will have the ultimate decision making authority
16once this document goes into effect, in most instances after
17you are no longer able to make your own decisions. While the
18goal is for your agent to make decisions in keeping with your
19preferences and in the majority of circumstances that is what
20happens, please know that the law does allow your agent to make
21decisions to direct or refuse health care interventions or
22withdraw treatment. Your agent will need to think about
23conversations you have had, your personality, and how you
24handled important health care issues in the past. Therefore, it
25is important to talk with your agent and your family about such



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1things as:
2        (i) What is most important to you in your life?
3        (ii) How important is it to you to avoid pain and
4    suffering?
5        (iii) If you had to choose, is it more important to you
6    to live as long as possible, or to avoid prolonged
7    suffering or disability?
8        (iv) Would you rather be at home or in a hospital for
9    the last days or weeks of your life?
10        (v) Do you have religious, spiritual, or cultural
11    beliefs that you want your agent and others to consider?
12        (vi) Do you wish to make a significant contribution to
13    medical science after your death through organ or whole
14    body donation?
15        (vii) Do you have an existing advanced directive, such
16    as a living will, that contains your specific wishes about
17    health care that is only delaying your death? If you have
18    another advance directive, make sure to discuss with your
19    agent the directive and the treatment decisions contained
20    within that outline your preferences. Make sure that your
21    agent agrees to honor the wishes expressed in your advance
22    directive.
24    If there is ever a period of time when your physician
25determines that you cannot make your own health care decisions,



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1or if you do not want to make your own decisions, some of the
2decisions your agent could make are to:
3        (i) talk with physicians and other health care
4    providers about your condition.
5        (ii) see medical records and approve who else can see
6    them.
7        (iii) give permission for medical tests, medicines,
8    surgery, or other treatments.
9        (iv) choose where you receive care and which physicians
10    and others provide it.
11        (v) decide to accept, withdraw, or decline treatments
12    designed to keep you alive if you are near death or not
13    likely to recover. You may choose to include guidelines
14    and/or restrictions to your agent's authority.
15        (vi) agree or decline to donate your organs or your
16    whole body if you have not already made this decision
17    yourself. This could include donation for transplant,
18    research, and/or education. You should let your agent know
19    whether you are registered as a donor in the First Person
20    Consent registry maintained by the Illinois Secretary of
21    State or whether you have agreed to donate your whole body
22    for medical research and/or education.
23        (vii) decide what to do with your remains after you
24    have died, if you have not already made plans.
25        (viii) talk with your other loved ones to help come to
26    a decision (but your designated agent will have the final



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1    say over your other loved ones).
2    Your agent is not automatically responsible for your health
3care expenses.
5    You can pick a family member, but you do not have to. Your
6agent will have the responsibility to make medical treatment
7decisions, even if other people close to you might urge a
8different decision. The selection of your agent should be done
9carefully, as he or she will have ultimate decision-making
10authority for your treatment decisions once you are no longer
11able to voice your preferences. Choose a family member, friend,
12or other person who:
13        (i) is at least 18 years old;
14        (ii) knows you well;
15        (iii) you trust to do what is best for you and is
16    willing to carry out your wishes, even if he or she may not
17    agree with your wishes;
18        (iv) would be comfortable talking with and questioning
19    your physicians and other health care providers;
20        (v) would not be too upset to carry out your wishes if
21    you became very sick; and
22        (vi) can be there for you when you need it and is
23    willing to accept this important role.



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2    If the person who is your first choice is unable to carry
3out this role, then the second agent you chose will make the
4decisions; if your second agent is not available, then the
5third agent you chose will make the decisions. The second and
6third agents are called your successor agents and they function
7as back-up agents to your first choice agent and may act only
8one at a time and in the order you list them.
11    If you become unable to make your own health care decisions
12and have not named an agent in writing, your physician and
13other health care providers will ask a family member, friend,
14or guardian to make decisions for you. In Illinois, a law
15directs which of these individuals will be consulted. In that
16law, each of these individuals is called a "surrogate".
17    There are reasons why you may want to name an agent rather
18than rely on a surrogate:
19        (i) The person or people listed by this law may not be
20    who you would want to make decisions for you.
21        (ii) Some family members or friends might not be able
22    or willing to make decisions as you would want them to.
23        (iii) Family members and friends may disagree with one
24    another about the best decisions.
25        (iv) Under some circumstances, a surrogate may not be



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1    able to make the same kinds of decisions that an agent can
2    make.
5    In this situation, it is especially important to talk to
6your physician and other health care providers and create
7written guidance about what you want or do not want, in case
8you are ever critically ill and cannot express your own wishes.
9You can complete a living will. You can also write your wishes
10down and/or discuss them with your physician or other health
11care provider and ask him or her to write it down in your
12chart. You might also want to use written or on-line resources
13to guide you through this process.
15    Follow these instructions after you have completed the
17        (i) Sign the form in front of a witness. See the form
18    for a list of who can and cannot witness it.
19        (ii) Ask the witness to sign it, too.
20        (iii) There is no need to have the form notarized.
21        (iv) Give a copy to your agent and to each of your
22    successor agents.
23        (v) Give another copy to your physician.
24        (vi) Take a copy with you when you go to the hospital.



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1        (vii) Show it to your family and friends and others who
2    care for you.
4    You may change your mind at any time. If you do, tell
5someone who is at least 18 years old that you have changed your
6mind, and/or destroy your document and any copies. If you wish,
7fill out a new form and make sure everyone you gave the old
8form to has a copy of the new one, including, but not limited
9to, your agents and your physicians.
11    In the event you do not want to use the Illinois statutory
12form provided here, any document you complete must be executed
13by you, designate an agent who is over 18 years of age and not
14prohibited from serving as your agent, and state the agent's
15powers, but it need not be witnessed or conform in any other
16respect to the statutory health care power.
17    If you have questions about the use of any form, you may
18want to consult your physician, other health care provider,
19and/or an attorney.

22FOR HEALTH CARE. (You must sign this form and a witness must



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1also sign it before it is valid)
2My name (Print your full name):..............................
3My address:..................................................
5(an agent is your personal representative under state and
6federal law):
7(Agent name).................................................
8(Agent address)..............................................
9(Agent phone number).........................................
11        (i) Deciding to accept, withdraw or decline treatment
12    for any physical or mental condition of mine, including
13    life-and-death decisions.
14        (ii) Agreeing to admit me to or discharge me from any
15    hospital, home, or other institution, including a mental
16    health facility.
17        (iii) Having complete access to my medical and mental
18    health records, and sharing them with others as needed,
19    including after I die.
20        (iv) Carrying out the plans I have already made, or, if
21    I have not done so, making decisions about my body or
22    remains, including organ, tissue or whole body donation,
23    autopsy, cremation, and burial.



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1    The above grant of power is intended to be as broad as
2possible so that my agent will have the authority to make any
3decision I could make to obtain or terminate any type of health
4care, including withdrawal of nutrition and hydration and other
5life-sustaining measures.
6I AUTHORIZE MY AGENT TO (please check any one box):
7    .... Make decisions for me only when I cannot make them for
8    myself. The physician(s) taking care of me will determine
9    when I lack this ability.
10        (If no box is checked, then the box above shall be
11    implemented.) OR
12    .... Make decisions for me starting now and continuing
13    after I am no longer able to make them for myself. While I
14    am still able to make my own decisions, I can still do so
15    if I want to.
16    The subject of life-sustaining treatment is of particular
17importance. Life-sustaining treatments may include tube
18feedings or fluids through a tube, breathing machines, and CPR.
19In general, in making decisions concerning life-sustaining
20treatment, your agent is instructed to consider the relief of
21suffering, the quality as well as the possible extension of
22your life, and your previously expressed wishes. Your agent
23will weigh the burdens versus benefits of proposed treatments
24in making decisions on your behalf.



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1    Additional statements concerning the withholding or
2removal of life-sustaining treatment are described below.
3These can serve as a guide for your agent when making decisions
4for you. Ask your physician or health care provider if you have
5any questions about these statements.
8    .... The quality of my life is more important than the
9    length of my life. If I am unconscious and my attending
10    physician believes, in accordance with reasonable medical
11    standards, that I will not wake up or recover my ability to
12    think, communicate with my family and friends, and
13    experience my surroundings, I do not want treatments to
14    prolong my life or delay my death, but I do want treatment
15    or care to make me comfortable and to relieve me of pain.
16    .... Staying alive is more important to me, no matter how
17    sick I am, how much I am suffering, the cost of the
18    procedures, or how unlikely my chances for recovery are. I
19    want my life to be prolonged to the greatest extent
20    possible in accordance with reasonable medical standards.
22    The above grant of power is intended to be as broad as
23possible so that your agent will have the authority to make any
24decision you could make to obtain or terminate any type of



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1health care. If you wish to limit the scope of your agent's
2powers or prescribe special rules or limit the power to
3authorize autopsy or dispose of remains, you may do so
4specifically in this form.
7My signature:................................................
8Today's date:................................................
11    I am at least 18 years old. (check one of the options
13    .... I saw the principal sign this document, or
14    .... the principal told me that the signature or mark on
15    the principal signature line is his or hers.
16    I am not the agent or successor agent(s) named in this
17document. I am not related to the principal, the agent, or the
18successor agent(s) by blood, marriage, or adoption. I am not
19the principal's physician, mental health service provider, or a
20relative of one of those individuals. I am not an owner or
21operator (or the relative of an owner or operator) of the
22health care facility where the principal is a patient or
24Witness printed name:........................................



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1Witness address:.............................................
2Witness signature:...........................................
3Today's date:................................................
5    If the agent I selected is unable or does not want to make
6health care decisions for me, then I request the person(s) I
7name below to be my successor health care agent(s). Only one
8person at a time can serve as my agent (add another page if you
9want to add more successor agent names):
11(Successor agent #1 name, address and phone number)
13(Successor agent #2 name, address and phone number)

16    PLEASE READ THIS NOTICE CAREFULLY. The form that you will
17be signing is a legal document. It is governed by the Illinois
18Power of Attorney Act. If there is anything about this form
19that you do not understand, you should ask a lawyer to explain
20it to you.
21    The purpose of this Power of Attorney is to give your
22designated "agent" broad powers to make health care decisions
23for you, including the power to require, consent to, or



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1withdraw treatment for any physical or mental condition, and to
2admit you or discharge you from any hospital, home, or other
3institution. You may name successor agents under this form, but
4you may not name co-agents.
5    This form does not impose a duty upon your agent to make
6such health care decisions, so it is important that you select
7an agent who will agree to do this for you and who will make
8those decisions as you would wish. It is also important to
9select an agent whom you trust, since you are giving that agent
10control over your medical decision-making, including
11end-of-life decisions. Any agent who does act for you has a
12duty to act in good faith for your benefit and to use due care,
13competence, and diligence. He or she must also act in
14accordance with the law and with the statements in this form.
15Your agent must keep a record of all significant actions taken
16as your agent.
17    Unless you specifically limit the period of time that this
18Power of Attorney will be in effect, your agent may exercise
19the powers given to him or her throughout your lifetime, even
20after you become disabled. A court, however, can take away the
21powers of your agent if it finds that the agent is not acting
22properly. You may also revoke this Power of Attorney if you
24    The Powers you give your agent, your right to revoke those
25powers, and the penalties for violating the law are explained
26more fully in Sections 4-5, 4-6, and 4-10(c) of the Illinois



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1Power of Attorney Act. This form is a part of that law. The
2"NOTE" paragraphs throughout this form are instructions.
3    You are not required to sign this Power of Attorney, but it
4will not take effect without your signature. You should not
5sign it if you do not understand everything in it, and what
6your agent will be able to do if you do sign it.
7    Please put your initials on the following line indicating
8that you have read this Notice:
(Principal's initials)"


13    1. I, ..................................................,
14(insert name and address of principal) hereby revoke all prior
15powers of attorney for health care executed by me and appoint:
17(insert name and address of agent)
18(NOTE: You may not name co-agents using this form.)
19as my attorney-in-fact (my "agent") to act for me and in my
20name (in any way I could act in person) to make any and all
21decisions for me concerning my personal care, medical
22treatment, hospitalization and health care and to require,
23withhold or withdraw any type of medical treatment or



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1procedure, even though my death may ensue.
2    A. My agent shall have the same access to my medical
3records that I have, including the right to disclose the
4contents to others.
5    B. Effective upon my death, my agent has the full power to
6make an anatomical gift of the following:
7(NOTE: Initial one. In the event none of the options are
8initialed, then it shall be concluded that you do not wish to
9grant your agent any such authority.)
10        .... Any organs, tissues, or eyes suitable for
11    transplantation or used for research or education.
12        .... Specific organs:................................
13        .... I do not grant my agent authority to make any
14    anatomical gifts.
15    C. My agent shall also have full power to authorize an
16autopsy and direct the disposition of my remains. I intend for
17this power of attorney to be in substantial compliance with
18Section 10 of the Disposition of Remains Act. All decisions
19made by my agent with respect to the disposition of my remains,
20including cremation, shall be binding. I hereby direct any
21cemetery organization, business operating a crematory or
22columbarium or both, funeral director or embalmer, or funeral
23establishment who receives a copy of this document to act under
25    D. I intend for the person named as my agent to be treated
26as I would be with respect to my rights regarding the use and



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1disclosure of my individually identifiable health information
2or other medical records, including records or communications
3governed by the Mental Health and Developmental Disabilities
4Confidentiality Act. This release authority applies to any
5information governed by the Health Insurance Portability and
6Accountability Act of 1996 ("HIPAA") and regulations
7thereunder. I intend for the person named as my agent to serve
8as my "personal representative" as that term is defined under
9HIPAA and regulations thereunder.
10    (i) The person named as my agent shall have the power to
11authorize the release of information governed by HIPAA to third
13    (ii) I authorize any physician, health care professional,
14dentist, health plan, hospital, clinic, laboratory, pharmacy
15or other covered health care provider, any insurance company
16and the Medical Informational Bureau, Inc., or any other health
17care clearinghouse that has provided treatment or services to
18me, or that has paid for or is seeking payment for me for such
19services to give, disclose, and release to the person named as
20my agent, without restriction, all of my individually
21identifiable health information and medical records, regarding
22any past, present, or future medical or mental health
23condition, including all information relating to the diagnosis
24and treatment of HIV/AIDS, sexually transmitted diseases, drug
25or alcohol abuse, and mental illness (including records or
26communications governed by the Mental Health and Developmental



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1Disabilities Confidentiality Act).
2    (iii) The authority given to the person named as my agent
3shall supersede any prior agreement that I may have with my
4health care providers to restrict access to, or disclosure of,
5my individually identifiable health information. The authority
6given to the person named as my agent has no expiration date
7and shall expire only in the event that I revoke the authority
8in writing and deliver it to my health care provider.
9(NOTE: The above grant of power is intended to be as broad as
10possible so that your agent will have the authority to make any
11decision you could make to obtain or terminate any type of
12health care, including withdrawal of food and water and other
13life-sustaining measures, if your agent believes such action
14would be consistent with your intent and desires. If you wish
15to limit the scope of your agent's powers or prescribe special
16rules or limit the power to make an anatomical gift, authorize
17autopsy or dispose of remains, you may do so in the following
19    2. The powers granted above shall not include the following
20powers or shall be subject to the following rules or
22(NOTE: Here you may include any specific limitations you deem
23appropriate, such as: your own definition of when
24life-sustaining measures should be withheld; a direction to
25continue food and fluids or life-sustaining treatment in all
26events; or instructions to refuse any specific types of



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1treatment that are inconsistent with your religious beliefs or
2unacceptable to you for any other reason, such as blood
3transfusion, electro-convulsive therapy, amputation,
4psychosurgery, voluntary admission to a mental institution,
11(NOTE: The subject of life-sustaining treatment is of
12particular importance. For your convenience in dealing with
13that subject, some general statements concerning the
14withholding or removal of life-sustaining treatment are set
15forth below. If you agree with one of these statements, you may
16initial that statement; but do not initial more than one. These
17statements serve as guidance for your agent, who shall give
18careful consideration to the statement you initial when
19engaging in health care decision-making on your behalf.)
20    I do not want my life to be prolonged nor do I want
21life-sustaining treatment to be provided or continued if my
22agent believes the burdens of the treatment outweigh the
23expected benefits. I want my agent to consider the relief of
24suffering, the expense involved and the quality as well as the
25possible extension of my life in making decisions concerning
26life-sustaining treatment.



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Initialed ...........................
2    I want my life to be prolonged and I want life-sustaining
3treatment to be provided or continued, unless I am, in the
4opinion of my attending physician, in accordance with
5reasonable medical standards at the time of reference, in a
6state of "permanent unconsciousness" or suffer from an
7"incurable or irreversible condition" or "terminal condition",
8as those terms are defined in Section 4-4 of the Illinois Power
9of Attorney Act. If and when I am in any one of these states or
10conditions, I want life-sustaining treatment to be withheld or
Initialed ...........................
13    I want my life to be prolonged to the greatest extent
14possible in accordance with reasonable medical standards
15without regard to my condition, the chances I have for recovery
16or the cost of the procedures.
Initialed ...........................
18(NOTE: This power of attorney may be amended or revoked by you
19in the manner provided in Section 4-6 of the Illinois Power of
20Attorney Act.)
21    3.   This power of attorney shall become effective on
24(NOTE: Insert a future date or event during your lifetime, such
25as a court determination of your disability or a written
26determination by your physician that you are incapacitated,



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1when you want this power to first take effect.)
2(NOTE: If you do not amend or revoke this power, or if you do
3not specify a specific ending date in paragraph 4, it will
4remain in effect until your death; except that your agent will
5still have the authority to donate your organs, authorize an
6autopsy, and dispose of your remains after your death, if you
7grant that authority to your agent.)
8    4.   This power of attorney shall terminate on ..........
10(NOTE: Insert a future date or event, such as a court
11determination that you are not under a legal disability or a
12written determination by your physician that you are not
13incapacitated, if you want this power to terminate prior to
14your death.)
15(NOTE: You cannot use this form to name co-agents. If you wish
16to name successor agents, insert the names and addresses of the
17successors in paragraph 5.)
18    5. If any agent named by me shall die, become incompetent,
19resign, refuse to accept the office of agent or be unavailable,
20I name the following (each to act alone and successively, in
21the order named) as successors to such agent:
24For purposes of this paragraph 5, a person shall be considered
25to be incompetent if and while the person is a minor, or an
26adjudicated incompetent or disabled person, or the person is



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1unable to give prompt and intelligent consideration to health
2care matters, as certified by a licensed physician.
3(NOTE: If you wish to, you may name your agent as guardian of
4your person if a court decides that one should be appointed. To
5do this, retain paragraph 6, and the court will appoint your
6agent if the court finds that this appointment will serve your
7best interests and welfare. Strike out paragraph 6 if you do
8not want your agent to act as guardian.)
9    6. If a guardian of my person is to be appointed, I
10nominate the agent acting under this power of attorney as such
11guardian, to serve without bond or security.
12    7. I am fully informed as to all the contents of this form
13and understand the full import of this grant of powers to my
15Dated: .......... 
Signed ..............................
(principal's signature or mark)
18    The principal has had an opportunity to review the above
19form and has signed the form or acknowledged his or her
20signature or mark on the form in my presence. The undersigned
21witness certifies that the witness is not: (a) the attending
22physician or mental health service provider or a relative of
23the physician or provider; (b) an owner, operator, or relative
24of an owner or operator of a health care facility in which the
25principal is a patient or resident; (c) a parent, sibling,



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1descendant, or any spouse of such parent, sibling, or
2descendant of either the principal or any agent or successor
3agent under the foregoing power of attorney, whether such
4relationship is by blood, marriage, or adoption; or (d) an
5agent or successor agent under the foregoing power of attorney.
(Witness Signature)
(Print Witness Name)
(Street Address)
(City, State, ZIP)
14(NOTE: You may, but are not required to, request your agent and
15successor agents to provide specimen signatures below. If you
16include specimen signatures in this power of attorney, you must
17complete the certification opposite the signatures of the
19Specimen signatures of    I certify that the signatures of my
20agent (and successors).   agent (and successors) are correct.
21.......................   ...................................
22       (agent)                      (principal)
23.......................   ...................................
24   (successor agent)                (principal)
25.......................   ...................................
26   (successor agent)                (principal)"



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1    (NOTE: The name, address, and phone number of the person
2preparing this form or who assisted the principal in completing
3this form is optional.)
(name of preparer)
11    (c) The statutory short form power of attorney for health
12care (the "statutory health care power") authorizes the agent
13to make any and all health care decisions on behalf of the
14principal which the principal could make if present and under
15no disability, subject to any limitations on the granted powers
16that appear on the face of the form, to be exercised in such
17manner as the agent deems consistent with the intent and
18desires of the principal. The agent will be under no duty to
19exercise granted powers or to assume control of or
20responsibility for the principal's health care; but when
21granted powers are exercised, the agent will be required to use
22due care to act for the benefit of the principal in accordance
23with the terms of the statutory health care power and will be
24liable for negligent exercise. The agent may act in person or
25through others reasonably employed by the agent for that



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1purpose but may not delegate authority to make health care
2decisions. The agent may sign and deliver all instruments,
3negotiate and enter into all agreements and do all other acts
4reasonably necessary to implement the exercise of the powers
5granted to the agent. Without limiting the generality of the
6foregoing, the statutory health care power shall include the
7following powers, subject to any limitations appearing on the
8face of the form:
9        (1) The agent is authorized to give consent to and
10    authorize or refuse, or to withhold or withdraw consent to,
11    any and all types of medical care, treatment or procedures
12    relating to the physical or mental health of the principal,
13    including any medication program, surgical procedures,
14    life-sustaining treatment or provision of food and fluids
15    for the principal.
16        (2) The agent is authorized to admit the principal to
17    or discharge the principal from any and all types of
18    hospitals, institutions, homes, residential or nursing
19    facilities, treatment centers and other health care
20    institutions providing personal care or treatment for any
21    type of physical or mental condition. The agent shall have
22    the same right to visit the principal in the hospital or
23    other institution as is granted to a spouse or adult child
24    of the principal, any rule of the institution to the
25    contrary notwithstanding.
26        (3) The agent is authorized to contract for any and all



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1    types of health care services and facilities in the name of
2    and on behalf of the principal and to bind the principal to
3    pay for all such services and facilities, and to have and
4    exercise those powers over the principal's property as are
5    authorized under the statutory property power, to the
6    extent the agent deems necessary to pay health care costs;
7    and the agent shall not be personally liable for any
8    services or care contracted for on behalf of the principal.
9        (4) At the principal's expense and subject to
10    reasonable rules of the health care provider to prevent
11    disruption of the principal's health care, the agent shall
12    have the same right the principal has to examine and copy
13    and consent to disclosure of all the principal's medical
14    records that the agent deems relevant to the exercise of
15    the agent's powers, whether the records relate to mental
16    health or any other medical condition and whether they are
17    in the possession of or maintained by any physician,
18    psychiatrist, psychologist, therapist, hospital, nursing
19    home or other health care provider. The authority under
20    this paragraph (4) applies to any information governed by
21    the Health Insurance Portability and Accountability Act of
22    1996 ("HIPAA") and regulations thereunder. The agent
23    serves as the principal's personal representative, as that
24    term is defined under HIPAA and regulations thereunder.
25        (5) The agent is authorized: to direct that an autopsy
26    be made pursuant to Section 2 of "An Act in relation to



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1    autopsy of dead bodies", approved August 13, 1965,
2    including all amendments; to make a disposition of any part
3    or all of the principal's body pursuant to the Illinois
4    Anatomical Gift Act, as now or hereafter amended; and to
5    direct the disposition of the principal's remains.
6(Source: P.A. 96-1195, eff. 7-1-11; 97-148, eff. 7-14-11.)
7    (755 ILCS 45/4-12)  (from Ch. 110 1/2, par. 804-12)
8    Sec. 4-12. Saving clause. This Act does not in any way
9invalidate any health care agency executed or any act of any
10agent done, or affect any claim, right or remedy that accrued,
11prior to September 22, 1987.
12    This amendatory Act of the 96th General Assembly does not
13in any way invalidate any health care agency executed or any
14act of any agent done, or affect any claim, right, or remedy
15that accrued, prior to the effective date of this amendatory
16Act of the 96th General Assembly.
17    This amendatory Act of the 98th General Assembly does not
18in any way invalidate any health care agency executed or any
19act of any agent done, or affect any claim, right, or remedy
20that accrued, prior to the effective date of this amendatory
21Act of the 98th General Assembly.
22(Source: P.A. 96-1195, eff. 7-1-11.)
23    Section 99. Effective date. This Act takes effect January
241, 2015.