Full Text of HB4136 96th General Assembly
HB4136 96TH GENERAL ASSEMBLY
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96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010 HB4136
Introduced 2/27/2009, by Rep. Patricia R. Bellock SYNOPSIS AS INTRODUCED: |
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755 ILCS 45/2-1 |
from Ch. 110 1/2, par. 802-1 |
755 ILCS 45/2-5 |
from Ch. 110 1/2, par. 802-5 |
755 ILCS 45/2-8 |
from Ch. 110 1/2, par. 802-8 |
755 ILCS 45/2-10 |
from Ch. 110 1/2, par. 802-10 |
755 ILCS 45/2-10.5 new |
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755 ILCS 45/2-10.6 new |
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755 ILCS 45/2-11 |
from Ch. 110 1/2, par. 802-11 |
755 ILCS 45/3-3 |
from Ch. 110 1/2, par. 803-3 |
755 ILCS 45/3-3.5 new |
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755 ILCS 45/3-3.6 new |
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755 ILCS 45/4-5.1 new |
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755 ILCS 45/4-10 |
from Ch. 110 1/2, par. 804-10 |
755 ILCS 45/4-12 |
from Ch. 110 1/2, par. 804-12 |
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Amends the Illinois Power of Attorney Act. Provides that an agent shall furnish a notarized certificate to the reliant (instead of the agent shall furnish a reliant an affidavit on demand stating that the principal is alive and the agent's powers have not been altered or terminated) which includes: the agent's duties; requirements that an agent avoid conflicts, keep records, and not commingle funds; awareness that liability may arise from a violation; and the principal is alive. Provides that a principal shall not have co-agents. Provides that a health care agency shall be witnessed by 2 people none of whom are: a medical care or other provider, or his or her relative; a parent, sibling, descendant, or any spouse of the principal or agent; or an agent or successor agent. Provides that an agent may make decisions concerning anatomical gifts and a person's remains. Provides that a power shall identify the person preparing the form. Provides that the health form must include a choice allowing the principal to have life prolonged unless permanently unconsciousness. Provides that if the power of attorney grants authority to co-agents, it shall be exercisable by majority vote, unless prompt action is required by one agent. Provides that an agent is not liable for another agent's actions unless the agent participates in or conceals a breach of fiduciary duty. Provides that these provisions do not invalidate any prior agency or any agent's act, or affect any claim that accrued before the effective date. Makes other changes.
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A BILL FOR
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HB4136 |
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LRB096 11759 AJO 22527 b |
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| AN ACT concerning civil law.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The Illinois Power of Attorney Act is amended by | 5 |
| changing Sections 2-1, 2-5, 2-8, 2-10, 2-11, 3-3, 4-10, and | 6 |
| 4-12 and by adding Sections 2-10.5, 2-10.6, 3-3.5, 3-3.6, and | 7 |
| 4-5.1, as follows:
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| (755 ILCS 45/2-1) (from Ch. 110 1/2, par. 802-1)
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| Sec. 2-1. Purpose. The General Assembly recognizes that | 10 |
| each
individual has the right to appoint an agent to make deal | 11 |
| with property , financial, or make
personal , and health care | 12 |
| decisions for the individual but that this right
cannot be | 13 |
| fully effective unless the principal may empower the agent to | 14 |
| act
throughout the principal's lifetime, including during | 15 |
| periods of
disability, and have confidence be sure that third | 16 |
| parties will honor the agent's authority
at all times.
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| The General Assembly finds that in the light of modern | 18 |
| financial needs
and advances in medical science, the statutory | 19 |
| recognition of this right of
delegation in Illinois needs to be | 20 |
| restated which will to , among other things, expand the
its | 21 |
| application and the permissible scope of the agent's authority, | 22 |
| clarify
the power of the individual to authorize an agent to | 23 |
| make financial and
care decisions for the individual and better |
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| protect health care personnel
and other third parties who rely | 2 |
| in good faith on the agent so that
reliance will be assured. | 3 |
| Nothing in this Act shall be deemed to
authorize or encourage | 4 |
| euthanasia, suicide or any action or course of
action that | 5 |
| violates the criminal law of this State or the United States.
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| Similarly, nothing in this Act shall be deemed to authorize or | 7 |
| encourage
any violation of a civil right expressed in the | 8 |
| Constitution, statutes,
case law and administrative rulings of | 9 |
| this State (including, without
limitation, the right of | 10 |
| conscience respected and protected by the Health
Care Right of | 11 |
| Conscience Act, as now or hereafter amended) or the
United | 12 |
| States or any action or course of action that violates the | 13 |
| public policy
expressed in the Constitution, statutes, case law | 14 |
| and administrative rulings of
this State or the United States.
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| (Source: P.A. 90-655, eff. 7-30-98.)
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| (755 ILCS 45/2-5) (from Ch. 110 1/2, par. 802-5)
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| Sec. 2-5. Duration of agency - amendment and revocation. | 18 |
| Unless the
agency states an earlier termination date, the | 19 |
| agency continues until the
death of the principal, | 20 |
| notwithstanding any lapse of time, the principal's
disability | 21 |
| or incapacity or appointment of a guardian for the principal
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| after the agency is signed. Every agency may be amended or | 23 |
| revoked by the
principal , if the principal has the capacity to | 24 |
| do so, at any time and in any manner communicated to the agent | 25 |
| or to any
other person related to the subject matter of the |
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| agency, except that
revocation and amendment of health care | 2 |
| agencies are governed by Section 4-6
of this Act except to the | 3 |
| extent the terms of the agencies are inconsistent
with that | 4 |
| Section.
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| (Source: P.A. 86-736.)
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| (755 ILCS 45/2-8) (from Ch. 110 1/2, par. 802-8)
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| Sec. 2-8.
Reliance on
document purporting to establish an
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| agency. Any person who acts in good faith
reliance on a copy of
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| a document purporting to establish an agency will be fully | 10 |
| protected and
released to
the same extent as though the reliant | 11 |
| had dealt directly with the
named
principal
as a | 12 |
| fully-competent person. The
named
agent shall furnish an | 13 |
| affidavit to the
reliant on demand stating that the instrument | 14 |
| relied on is a true copy of
the agency and that, to the best of | 15 |
| the
named
agent's knowledge, the named principal is
alive and | 16 |
| the relevant powers of the
named
agent have not been altered or
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| terminated; but good faith reliance on
a document purporting to | 18 |
| establish an agency will protect the reliant
without the | 19 |
| affidavit. | 20 |
| (a) Upon request, the named agent in a power of attorney | 21 |
| shall furnish a Certification and Acceptance of Authority to | 22 |
| the reliant in substantially the following form: | 23 |
| AGENT'S CERTIFICATION AND ACCEPTANCE |
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| I, (Name of Agent), certify that the attached is a true | 2 |
| copy of a Power of Attorney naming the undersigned as agent or | 3 |
| successor agent for (Name of Principal); and | 4 |
| I certify that to the best of my knowledge the Principal is | 5 |
| alive and has not revoked the Power of Attorney and that my | 6 |
| powers as agent have not been altered or terminated and that | 7 |
| the Power of Attorney remains in full force and effect. | 8 |
| I accept appointment as agent under this Power of Attorney. | 9 |
| Dated:............ | 10 |
| .......................
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| (Agent's Signature)
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| .......................
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| (Print Agent's Name)
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| .......................
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| (Agent's Address)
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| This document was acknowledged, signed and sworn to before | 17 |
| me on (date) by (Name of Agent). | 18 |
| [SEAL] | 19 |
| My commission expires............. ..................... | 20 |
| (Signature of Notary)
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| (b) Any person dealing with an agent
named in a copy of a | 22 |
| document purporting to establish an agency
may presume, in
the | 23 |
| absence of actual knowledge to the contrary, that the
document |
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| purporting to establish the
agency was
validly executed,
that | 2 |
| the agency was validly established,
that the named principal | 3 |
| was competent at the time
of execution, and that, at the time | 4 |
| of reliance, the
named
principal is alive,
the agency
was | 5 |
| validly established
and has not terminated or been amended, the | 6 |
| relevant powers of the
named
agent were properly and validly | 7 |
| granted and have not terminated or
been amended, and the acts | 8 |
| of the
named
agent conform to the standards of this Act.
No | 9 |
| person relying on
a copy of a document purporting to establish | 10 |
| an agency shall be required to see to the application
of any | 11 |
| property delivered to or controlled by the
named
agent or to | 12 |
| question the
authority of the
named
agent. | 13 |
| (c) Each person to whom a direction by the named agent in
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| accordance with the terms of the
copy of the document | 15 |
| purporting to establish an
agency is communicated shall comply | 16 |
| with
that direction, and any person who fails to comply | 17 |
| arbitrarily or without
reasonable cause shall be subject to | 18 |
| civil liability for any damages
resulting from noncompliance.
A | 19 |
| health care provider who complies with Section 4-7 shall not be
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| deemed to have acted arbitrarily or without reasonable cause.
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| (Source: P.A. 90-21, eff. 6-20-97.)
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| (755 ILCS 45/2-10) (from Ch. 110 1/2, par. 802-10)
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| Sec. 2-10. Agency-court relationship. | 24 |
| (a) Upon petition by any interested
person (including the | 25 |
| agent), with such notice to interested persons as the
court |
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| directs and a finding by the court that the principal
lacks | 2 |
| either the capacity to control or the capacity to revoke the | 3 |
| agency , the court may construe a power of attorney, review the | 4 |
| agent's conduct, and grant appropriate relief including | 5 |
| compensatory damages. : (a) if | 6 |
| (b) If the court finds
that the agent is not acting for the | 7 |
| benefit of the principal in accordance
with the terms of the | 8 |
| agency or that the agent's action or inaction has
caused or | 9 |
| threatens substantial harm to the principal's person or | 10 |
| property
in a manner not authorized or intended by the | 11 |
| principal, the court may
order a guardian of the principal's | 12 |
| person or estate to exercise any powers
of the principal under | 13 |
| the agency, including the power to revoke the
agency, or may | 14 |
| enter such other orders without appointment of a guardian as
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| the court deems necessary to provide for the best interests of | 16 |
| the
principal . | 17 |
| (c) If ; or (b) if the court finds that the agency requires
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| interpretation, the court may construe the agency and instruct | 19 |
| the agent,
but the court may not amend the agency. | 20 |
| (d) If the court finds that the agent has not acted for the | 21 |
| benefit of the principal in accordance with the terms of the | 22 |
| agency and the Illinois Power of Attorney Act, or that the | 23 |
| agent's action or inaction caused or threatened substantial | 24 |
| harm to the principal's person or property in a manner not | 25 |
| authorized or intended by the principal, then the agent shall | 26 |
| not be authorized to pay or be reimbursed from the estate of |
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| the principal the attorneys' fees and costs of the agent in | 2 |
| defending a proceeding brought pursuant to this Section. | 3 |
| (e) Upon a finding that the agent's action has caused | 4 |
| substantial harm to the principal's person or property, the | 5 |
| Court may assess against the agent reasonable costs and | 6 |
| attorney's fees to a prevailing party who is a provider agency | 7 |
| as defined in Section 2 of the Elder Abuse and Neglect Act, a | 8 |
| representative of the Office of the State Long Term Care | 9 |
| Ombudsman, or a governmental agency having regulatory | 10 |
| authority to protect the welfare of the principal. | 11 |
| (f) An interested person under this Section includes (1) | 12 |
| the principal or the agent; (2) a guardian of the person, | 13 |
| guardian of the estate, or other fiduciary charged with | 14 |
| management of the principal's property; (3) the principal's | 15 |
| spouse, parent, or descendant; (4) a person who would be a | 16 |
| presumptive heir-at-law of the principal: (5) a person named as | 17 |
| a beneficiary to receive any property, benefit, or contractual | 18 |
| right on the principal's death, or as a beneficiary of a trust | 19 |
| created by or for the principal; (6) a provider agency as | 20 |
| defined in Section 2 of the Elder Abuse and Neglect Act, a | 21 |
| representative of the Office of the State Long Term Care | 22 |
| Ombudsman, or a governmental agency having regulatory | 23 |
| authority to protect the welfare of the principal; and (7) the | 24 |
| principal's caregiver or another person who demonstrates | 25 |
| sufficient interest in the principal's welfare. | 26 |
| (g) Absent court order directing a
guardian to exercise |
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| powers of the principal under the agency, a guardian
will have | 2 |
| no power, duty or liability with respect to any property | 3 |
| subject
to the agency or any personal or health care matters | 4 |
| covered by the agency. | 5 |
| (h)
Proceedings under this Section shall be commenced in | 6 |
| the county where the
guardian was appointed or, if no Illinois | 7 |
| guardian is acting, then in the
county where the agent or | 8 |
| principal resides or owns real property , if the agent does not | 9 |
| reside in
Illinois, then in any county .
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| (i) This Section shall not be construed to limit any other | 11 |
| remedies available. | 12 |
| (Source: P.A. 85-701.)
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| (755 ILCS 45/2-10.5 new)
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| Sec. 2-10.5. Co-agents and successor agents. | 15 |
| (a) Unless the power of attorney or this Section otherwise | 16 |
| provides, authority granted to 2 or more co-agents is | 17 |
| exercisable only by their majority consent. However, if prompt | 18 |
| action is required to accomplish the purposes of the power of | 19 |
| attorney or to avoid irreparable injury to the principal's | 20 |
| interests and an agent is unavailable because of absence, | 21 |
| illness, or other temporary incapacity, the other agent or | 22 |
| agents may act for the principal. If a vacancy occurs in one or | 23 |
| more of the designations of agent under a power of attorney, | 24 |
| the remaining agent or agents may act for the principal. | 25 |
| (b) A principal may designate one or more successor agents |
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| to act if an initial or predecessor agent resigns, dies, | 2 |
| becomes incapacitated, is not qualified to serve, or declines | 3 |
| to serve. A principal may grant authority to another person, | 4 |
| designated by name, by office, or by function, including an | 5 |
| initial or successor agent, to designate one or more successor | 6 |
| agents. Unless a power of attorney otherwise provides, a | 7 |
| successor agent has the same authority as that granted to an | 8 |
| initial agent. | 9 |
| (c) An agent is not liable for the actions of another | 10 |
| agent, including a predecessor agent, unless the agent | 11 |
| participates in or conceals a breach of fiduciary duty | 12 |
| committed by the other agent. An agent who has knowledge of a | 13 |
| breach or imminent breach of fiduciary duty by another agent | 14 |
| must notify the principal and, if the principal is | 15 |
| incapacitated, take whatever actions may be reasonably | 16 |
| appropriate in the circumstances to safeguard the principal's | 17 |
| best interest. | 18 |
| (d) Any person who acts in good faith reliance on the | 19 |
| representation of a co-agent or successor agent regarding the | 20 |
| unavailability of the primary agent or one or more co-agents, | 21 |
| or the need for prompt action to accomplish the purposes of the | 22 |
| power of attorney or to avoid irreparable injury to the | 23 |
| principal's interests, will be fully protected and released to | 24 |
| the same extent as though the reliant had dealt directly with | 25 |
| all named agents. Upon request, the named agent in a Power of | 26 |
| Attorney for Property shall furnish a Certification and |
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| Acceptance of Authority to the reliant in substantially the | 2 |
| following form:
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| AGENT'S CERTIFICATION AND ACCEPTANCE | 4 |
| I certify that to the best of my knowledge that the | 5 |
| following named agent is unavailable due to (death, | 6 |
| resignation, absence, illness, or other temporary incapacity) | 7 |
| (circle reason). | 8 |
| I certify that prompt action is required to accomplish the | 9 |
| purposes of the power of attorney or to avoid irreparable | 10 |
| injury to the principal's interests. | 11 |
| I accept appointment as agent under this Power of Attorney. | 12 |
| Dated:............ | 13 |
| .......................
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| (Agent's Signature)
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| .......................
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| (Print Agent's Name)
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| .......................
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| (Agent's Address)
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| This document was acknowledged, signed and sworn to before | 20 |
| me on (date) by (Name of Agent). | 21 |
| [SEAL] | 22 |
| My commission expires.......... | 23 |
| ......................
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| (Signature of Notary)
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| (755 ILCS 45/2-10.6 new)
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| Sec. 2-10.6. Power of attorney executed in another state or | 3 |
| country; pre-existing powers of attorney. | 4 |
| (a) A power of attorney executed in another state or | 5 |
| country is valid and enforceable in this State if its creation | 6 |
| complied when executed with: | 7 |
| (1) the law of the state or country in which the power | 8 |
| of attorney was executed; | 9 |
| (2) the law of this State; | 10 |
| (3) the law of the state or country where the principal | 11 |
| is domiciled, has a place of abode or business, or is a | 12 |
| national; or | 13 |
| (4) the law of the state or country where the agent is | 14 |
| domiciled or has a place of business. | 15 |
| (b) A power of attorney executed in this State before the | 16 |
| effective date of this amendatory Act of the 96th General | 17 |
| Assembly is valid and enforceable in this State if its creation | 18 |
| complied with the law of this State as it existed at the time | 19 |
| of execution.
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| (755 ILCS 45/2-11) (from Ch. 110 1/2, par. 802-11)
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| Sec. 2-11. Saving clause. This Act does not in any way
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| invalidate any agency executed or any act of any agent done, or
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| affect any claim, right or remedy that accrued, prior to
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| September 22, 1987.
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| This amendatory Act of the 96th General Assembly does not |
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| in any way invalidate any agency executed or any act of any | 2 |
| agent done, or affect any claim, right, or remedy that accrued | 3 |
| prior to the effective date of this amendatory Act of the 96th | 4 |
| General Assembly. | 5 |
| (Source: P.A. 86-736.)
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| (755 ILCS 45/3-3) (from Ch. 110 1/2, par. 803-3)
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| Sec. 3-3. Statutory short form power of attorney for | 8 |
| property. The
following form may be known as "statutory | 9 |
| property power" and may be used
to grant an agent powers with | 10 |
| respect to property and financial matters.
When a power of | 11 |
| attorney in substantially the following form is used,
including | 12 |
| the "notice" paragraph at the beginning of the form on a | 13 |
| separate sheet in 14-point type in capital letters and
the | 14 |
| notarized form of acknowledgment at the end, it shall have the | 15 |
| meaning
and effect prescribed in this Act. Such a document | 16 |
| shall be deemed to be substantially the same format as the | 17 |
| statutory form if the explanatory language throughout the | 18 |
| document is distinguished in some way from the legal paragraphs | 19 |
| in the form, such as italicization or other difference in type | 20 |
| face or point size, if the "notice" paragraphs at the beginning | 21 |
| are not on a separate sheet of paper or are not in 14-point | 22 |
| type, or if the principal's initials do not appear in the | 23 |
| acknowledgement at the end of the "notice" paragraphs. The | 24 |
| validity of a power of attorney as
meeting the requirements of | 25 |
| a statutory property power shall not be
affected by the fact |
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| that one or more of the categories of optional powers
listed in | 2 |
| the form are struck out or the form includes specific
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| limitations on or additions to the agent's powers, as permitted | 4 |
| by the
form. Nothing in this Article shall invalidate or bar | 5 |
| use by the
principal of any other or different form of power of | 6 |
| attorney for property.
Nonstatutory property powers must be | 7 |
| executed by the principal and
designate the agent and the | 8 |
| agent's powers, but they need not be acknowledged
or
conform in | 9 |
| any other respect to the statutory property power.
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| "NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS | 11 |
| STATUTORY SHORT FORM POWER OF ATTORNEY FOR PROPERTY. | 12 |
| PLEASE READ THIS NOTICE CAREFULLY. The form that you will | 13 |
| be signing is a legal document. It is governed by the Illinois | 14 |
| Power of Attorney Act. If there is anything about this form | 15 |
| that you do not understand, you should ask a lawyer to explain | 16 |
| it to you. | 17 |
| The purpose of this Power of Attorney is to give your | 18 |
| designated "agent" broad powers to handle your financial | 19 |
| affairs, which may include the power to pledge, sell, or | 20 |
| dispose of any of your real or personal property, even without | 21 |
| your consent or any advance notice to you. You may name | 22 |
| successor agents under this form, but you may not name | 23 |
| co-agents. |
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| This form does not impose a duty upon your agent to handle | 2 |
| your financial affairs, so it is important that you select an | 3 |
| agent who will agree to do this for you. It is also important | 4 |
| to select an agent whom you trust, since you are giving that | 5 |
| agent control over your financial assets and property. Any | 6 |
| agent who does act for you has a duty to use due care to act for | 7 |
| your benefit. He or she must also act in accordance with the | 8 |
| law and with the directions in this form. Your agent must keep | 9 |
| a record of all receipts, disbursements, and significant | 10 |
| actions taken as your agent. | 11 |
| Unless you specifically limit the period of time that this | 12 |
| Power of Attorney will be in effect, your agent may exercise | 13 |
| the powers given to him or her throughout your lifetime, both | 14 |
| before and after you become incapacitated. A court, however, | 15 |
| can take away the powers of your agent if it finds that the | 16 |
| agent is not acting properly. You may also revoke this Power of | 17 |
| Attorney if you wish. | 18 |
| The Powers you give your agent are explained more fully in | 19 |
| Section 3-4 of the Illinois "Statutory Short Form Power of | 20 |
| Attorney for Property Law". This form is a part of that law. | 21 |
| You are not required to sign this Power of Attorney. You | 22 |
| should not sign the Power of Attorney if you do not understand | 23 |
| everything in it, and what your agent will be able to do if you |
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| do sign it. | 2 |
| Please place your initials on the following line indicating | 3 |
| that you have read this Notice: | 4 |
| .....................
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| Principal's initials"
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| "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR PROPERTY
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| (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE | 8 |
| THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE | 9 |
| YOUR PROPERTY, WHICH MAY
INCLUDE POWERS TO PLEDGE, SELL OR | 10 |
| OTHERWISE DISPOSE OF ANY REAL OR PERSONAL
PROPERTY WITHOUT | 11 |
| ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS FORM DOES
NOT | 12 |
| IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT | 13 |
| WHEN POWERS
ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE | 14 |
| TO ACT FOR YOUR
BENEFIT AND IN ACCORDANCE WITH THIS FORM AND | 15 |
| KEEP A RECORD OF RECEIPTS,
DISBURSEMENTS AND SIGNIFICANT | 16 |
| ACTIONS TAKEN AS AGENT. A COURT CAN TAKE AWAY THE POWERS
OF | 17 |
| YOUR AGENT IF IT FINDS THE AGENT IS NOT ACTING PROPERLY. YOU | 18 |
| MAY NAME
SUCCESSOR AGENTS UNDER THIS FORM BUT NOT CO-AGENTS. | 19 |
| UNLESS YOU EXPRESSLY
LIMIT THE DURATION OF THIS POWER IN THE | 20 |
| MANNER PROVIDED BELOW, UNTIL YOU
REVOKE THIS POWER OR A COURT | 21 |
| ACTING ON YOUR BEHALF TERMINATES IT, YOUR
AGENT MAY EXERCISE | 22 |
| THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN
AFTER YOU | 23 |
| BECOME DISABLED. THE POWERS YOU GIVE YOUR AGENT ARE EXPLAINED
| 24 |
| MORE FULLY IN SECTION 3-4 OF THE ILLINOIS "STATUTORY SHORT FORM | 25 |
| POWER OF
ATTORNEY FOR PROPERTY LAW" OF WHICH THIS FORM IS A |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| PART
(SEE THE BACK OF THIS FORM). THAT LAW EXPRESSLY PERMITS | 2 |
| THE USE OF ANY
DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY | 3 |
| DESIRE. IF THERE IS ANYTHING
ABOUT THIS FORM THAT YOU DO NOT | 4 |
| UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN
IT TO YOU.)
| 5 |
| POWER OF ATTORNEY made this .... day of ....... (month) | 6 |
| ...... (year)
| 7 |
| 1. I, ..............., (insert name and address of | 8 |
| principal)
hereby appoint:
| 9 |
| .............................................................
| 10 |
| (insert name and address of agent)
| 11 |
| as my attorney-in-fact (my "agent") to act for me and in my | 12 |
| name (in any
way I could act in person) with respect to the | 13 |
| following powers, as defined
in Section 3-4 of the "Statutory | 14 |
| Short Form Power of Attorney for Property Law"
(including all | 15 |
| amendments), but subject to any limitations on or additions
to | 16 |
| the specified powers inserted in paragraph 2 or 3 below:
| 17 |
| (YOU MUST STRIKE OUT ANY ONE OR MORE OF THE FOLLOWING | 18 |
| CATEGORIES OF
POWERS YOU DO NOT WANT YOUR AGENT TO HAVE. | 19 |
| FAILURE TO STRIKE THE TITLE
OF ANY CATEGORY WILL CAUSE THE | 20 |
| POWERS DESCRIBED IN THAT CATEGORY TO BE
GRANTED TO THE AGENT. | 21 |
| TO STRIKE OUT A CATEGORY YOU MUST DRAW A LINE
THROUGH THE TITLE | 22 |
| OF THAT CATEGORY.)
| 23 |
| (a) Real estate transactions.
| 24 |
| (b) Financial institution transactions.
| 25 |
| (c) Stock and bond transactions.
|
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| (d) Tangible personal property transactions.
| 2 |
| (e) Safe deposit box transactions.
| 3 |
| (f) Insurance and annuity transactions.
| 4 |
| (g) Retirement plan transactions.
| 5 |
| (h) Social Security, employment and military service | 6 |
| benefits.
| 7 |
| (i) Tax matters.
| 8 |
| (j) Claims and litigation.
| 9 |
| (k) Commodity and option transactions.
| 10 |
| (l) Business operations.
| 11 |
| (m) Borrowing transactions.
| 12 |
| (n) Estate transactions.
| 13 |
| (o) All other property powers and transactions.
| 14 |
| (LIMITATIONS ON AND ADDITIONS TO THE AGENT'S POWERS MAY BE | 15 |
| INCLUDED IN THIS
POWER OF ATTORNEY IF THEY ARE SPECIFICALLY | 16 |
| DESCRIBED BELOW.)
| 17 |
| 2. The powers granted above shall not include the following | 18 |
| powers or
shall be modified or limited in the following | 19 |
| particulars (here you may
include any specific limitations you | 20 |
| deem appropriate, such as a
prohibition or conditions on the | 21 |
| sale of particular stock or real estate or
special rules on | 22 |
| borrowing by the agent):
| 23 |
| .............................................................
| 24 |
| .............................................................
| 25 |
| .............................................................
| 26 |
| .............................................................
|
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| .............................................................
| 2 |
| 3. In addition to the powers granted above, I grant my | 3 |
| agent the
following powers (here you may add any other | 4 |
| delegable powers including,
without limitation, power to make | 5 |
| gifts, exercise powers of appointment,
name or change | 6 |
| beneficiaries or joint tenants or revoke or amend any trust
| 7 |
| specifically referred to below):
| 8 |
| .............................................................
| 9 |
| .............................................................
| 10 |
| .............................................................
| 11 |
| .............................................................
| 12 |
| .............................................................
| 13 |
| (YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS | 14 |
| NECESSARY TO
ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS | 15 |
| GRANTED IN THIS FORM, BUT
YOUR AGENT WILL HAVE TO MAKE ALL | 16 |
| DISCRETIONARY DECISIONS. IF YOU WANT TO
GIVE YOUR AGENT THE | 17 |
| RIGHT TO DELEGATE DISCRETIONARY DECISION-MAKING POWERS
TO | 18 |
| OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD | 19 |
| BE STRUCK OUT.)
| 20 |
| 4. My agent shall have the right by written instrument to | 21 |
| delegate any
or all of the foregoing powers involving | 22 |
| discretionary decision-making to
any person or persons whom my | 23 |
| agent may select, but such delegation may be
amended or revoked | 24 |
| by any agent (including any successor) named by me who
is | 25 |
| acting under this power of attorney at the time of reference.
| 26 |
| (YOUR AGENT WILL BE ENTITLED TO REIMBURSEMENT FOR ALL |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| REASONABLE EXPENSES
INCURRED IN ACTING UNDER THIS POWER OF | 2 |
| ATTORNEY. STRIKE OUT THE NEXT
SENTENCE IF YOU DO NOT WANT YOUR | 3 |
| AGENT TO ALSO BE ENTITLED TO REASONABLE
COMPENSATION FOR | 4 |
| SERVICES AS AGENT.)
| 5 |
| 5. My agent shall be entitled to reasonable compensation | 6 |
| for services
rendered as agent under this power of attorney.
| 7 |
| (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU AT ANY | 8 |
| TIME AND IN
ANY MANNER. ABSENT AMENDMENT OR REVOCATION, THE | 9 |
| AUTHORITY GRANTED IN THIS
POWER OF ATTORNEY WILL BECOME | 10 |
| EFFECTIVE AT THE TIME THIS POWER IS SIGNED
AND WILL CONTINUE | 11 |
| UNTIL YOUR DEATH UNLESS A LIMITATION ON THE BEGINNING
DATE OR | 12 |
| DURATION IS MADE BY INITIALING AND COMPLETING EITHER (OR BOTH) | 13 |
| OF
THE FOLLOWING:)
| 14 |
| 6. ( ) This power of attorney shall become effective on
| 15 |
| .............................................................
| 16 |
| (insert a future date or event during your lifetime, such as | 17 |
| court
determination of your disability, when you want this | 18 |
| power to first take effect)
| 19 |
| 7. ( ) This power of attorney shall terminate on
| 20 |
| .............................................................
| 21 |
| (insert a future date or event, such as court determination of | 22 |
| your
disability, when you want this power to terminate prior to | 23 |
| your death)
| 24 |
| (IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND | 25 |
| ADDRESS(ES)
OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.)
| 26 |
| 8. If any agent named by me shall die, become incompetent, |
|
|
|
HB4136 |
- 20 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| resign
or refuse to accept the office of agent, I name the | 2 |
| following
(each to act alone and successively,
in the order | 3 |
| named) as successor(s) to such agent:
| 4 |
| .............................................................
| 5 |
| .............................................................
| 6 |
| For purposes of this paragraph 8, a person shall be considered | 7 |
| to be
incompetent if and while the person is a minor or an | 8 |
| adjudicated
incompetent or disabled person or the person is | 9 |
| unable to give prompt and
intelligent consideration to business | 10 |
| matters, as certified by a licensed physician.
(IF YOU WISH TO | 11 |
| NAME YOUR AGENT AS
GUARDIAN OF YOUR ESTATE, IN THE EVENT A | 12 |
| COURT DECIDES THAT ONE
SHOULD BE APPOINTED, YOU
MAY, BUT ARE | 13 |
| NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING PARAGRAPH.
| 14 |
| THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS THAT SUCH | 15 |
| APPOINTMENT WILL SERVE YOUR
BEST INTERESTS AND WELFARE. STRIKE | 16 |
| OUT PARAGRAPH 9 IF YOU DO NOT WANT
YOUR AGENT TO ACT AS | 17 |
| GUARDIAN.)
| 18 |
| 9. If a guardian of my estate (my property) is to be | 19 |
| appointed, I
nominate the agent acting under this power of | 20 |
| attorney as such guardian,
to serve without bond or security.
| 21 |
| 10. I am fully informed as to all the contents of this form | 22 |
| and
understand the full import of this grant of powers to my | 23 |
| agent.
| 24 |
| Signed ..................................................
| 25 |
| (principal)
| 26 |
| (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND |
|
|
|
HB4136 |
- 21 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| SUCCESSOR
AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU | 2 |
| INCLUDE SPECIMEN
SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST | 3 |
| COMPLETE THE CERTIFICATION
OPPOSITE THE SIGNATURES OF THE | 4 |
| AGENTS.)
| 5 |
| Specimen signatures of I certify that the signatures
| 6 |
| agent (and successors) of my agent (and successors)
| 7 |
| are correct.
| 8 |
| .......................... .............................
| 9 |
| (agent) (principal)
| 10 |
| .......................... .............................
| 11 |
| (successor agent) (principal)
| 12 |
| .......................... .............................
| 13 |
| (successor agent) (principal)
| 14 |
| (THIS POWER OF ATTORNEY WILL NOT BE EFFECTIVE UNLESS IT IS | 15 |
| NOTARIZED AND
SIGNED BY AT LEAST ONE ADDITIONAL WITNESS,
USING | 16 |
| THE FORM BELOW.)
| 17 |
| State of ............)
| 18 |
| ) SS.
| 19 |
| County of ...........)
| 20 |
| The undersigned, a notary public in and for the above | 21 |
| county and state,
certifies that ......................., | 22 |
| known to me to be the same person
whose name is subscribed as | 23 |
| principal to the foregoing power of attorney,
appeared before | 24 |
| me and the additional witness in person and acknowledged
| 25 |
| signing and delivering the
instrument as the free and voluntary | 26 |
| act of the principal, for the uses and
purposes therein set |
|
|
|
HB4136 |
- 22 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| forth (, and certified to the correctness of the
signature(s) | 2 |
| of the agent(s)).
| 3 |
| Dated: ................ (SEAL)
| 4 |
| ..............................
| 5 |
| Notary Public
| 6 |
| My commission expires .................
| 7 |
| The undersigned witness certifies that ................, known | 8 |
| to me to be
the same person whose name is subscribed as | 9 |
| principal to the foregoing power of
attorney, appeared before | 10 |
| me and the notary public and acknowledged signing and
| 11 |
| delivering the instrument as the free and voluntary act of the | 12 |
| principal, for
the
uses and purposes therein set forth. I | 13 |
| believe him or her to be of sound mind
and memory.
| 14 |
| Dated: ................ (SEAL)
| 15 |
| ..............................
| 16 |
| Witness
| 17 |
| (THE NAME , AND ADDRESS , AND PHONE NUMBER OF THE PERSON | 18 |
| PREPARING THIS FORM OR WHO ASSISTED THE PRINCIPAL IN COMPLETING | 19 |
| THIS FORM SHOULD BE INSERTED BELOW SHOULD BE
INSERTED
IF THE | 20 |
| AGENT WILL HAVE POWER TO CONVEY ANY INTEREST IN REAL ESTATE .)
| 21 |
| .................... | 22 |
| (Name) | 23 |
| .................... | 24 |
| (Address) | 25 |
| .................... | 26 |
| (Phone) |
|
|
|
HB4136 |
- 23 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| This document was prepared by:
| 2 |
| .............................................................
| 3 |
| ............................................................."
| 4 |
| The requirement of the signature of an additional
witness | 5 |
| imposed by this amendatory Act of the 91st General
Assembly | 6 |
| applies only to instruments executed on or after
the effective | 7 |
| date of this amendatory Act of the 91st
General Assembly.
| 8 |
| (Source: P.A. 91-790, eff. 6-9-00 .)
| 9 |
| (755 ILCS 45/3-3.5 new) | 10 |
| Sec. 3-3.5. Notice to agent. The following form may be | 11 |
| known as "notice to agent" and may be supplied to an agent | 12 |
| appointed under a power of attorney for property. | 13 |
| "IMPORTANT INFORMATION FOR AGENT | 14 |
| When you accept the authority granted under this power of | 15 |
| attorney a special legal relationship, known as agency, is | 16 |
| created between you and the principal. Agency imposes upon you | 17 |
| duties that continue until you resign or the power of attorney | 18 |
| is terminated or revoked. | 19 |
| As agent you must: | 20 |
| (1) do what you know the principal reasonably expects you | 21 |
| to do with the principal's property; | 22 |
| (2) act in good faith with care, competence, and diligence | 23 |
| for the best interest of the principal; | 24 |
| (3) keep a complete record of all receipts, disbursements | 25 |
| and transactions conducted for the principal; and |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| (4) preserve the principal's estate plan to the extent you | 2 |
| know the plan, unless preserving the estate plan is | 3 |
| inconsistent with the principal's best interest. | 4 |
| As agent you must not: | 5 |
| (1) engage in conflicts that would impair your ability to | 6 |
| act in the principal's best interest; | 7 |
| (2) do any act beyond the authority granted in this power | 8 |
| of attorney; | 9 |
| (3) commingle the principal's funds with your funds; | 10 |
| (4) borrow funds or other property from the principal, | 11 |
| unless otherwise authorized; and | 12 |
| (5) continue acting on behalf of the principal if you learn | 13 |
| of any event which terminates this power of attorney or your | 14 |
| authority under this power of attorney. | 15 |
| If you have special skills or expertise, you must use those | 16 |
| special skills and expertise when acting for the principal. You | 17 |
| must disclose your identity as an agent whenever you act for | 18 |
| the principal by writing or printing the name of the principal | 19 |
| and signing your own name as "agent" in the following manner: | 20 |
| "(Principal's Name) by (Your Name) as Agent" | 21 |
| The meaning of the powers granted to you is contained in | 22 |
| the "Explanation of the powers granted in the statutory short | 23 |
| form power of attorney for property" attached to the Illinois | 24 |
| Short Form Power of Attorney for Property and in the body of | 25 |
| the power of attorney for property document. | 26 |
| If you violate your duties as agent or act outside the |
|
|
|
HB4136 |
- 25 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| authority granted to you, you may be liable for any damages, | 2 |
| including attorney's fees and costs, caused by your violation." | 3 |
| (755 ILCS 45/3-3.6 new) | 4 |
| Sec. 3-3.6. Limitations on who may witness property powers. | 5 |
| Every property power shall bear the signatures of 2 witnesses | 6 |
| to the signing of the agency. None of the following may serve | 7 |
| as a witness to the signing of a property power: | 8 |
| (a) the attending physician or mental health service | 9 |
| provider or relative of the physician or provider; | 10 |
| (b) an owner, operator, or relative of an owner or operator | 11 |
| of a health care facility in which the principal is a patient | 12 |
| or resident; | 13 |
| (c) a parent, sibling, descendant, or any spouse of such | 14 |
| parent, sibling, or descendant of either the principal or any | 15 |
| agent or successor agent, whether such relationship is by | 16 |
| blood, marriage, or adoption; or | 17 |
| (d) any agent or successor agent. | 18 |
| (755 ILCS 45/4-5.1 new) | 19 |
| Sec. 4-5.1. Limitations on who may witness health care | 20 |
| agencies. Every health care agency shall bear the signatures of | 21 |
| 2 witnesses to the signing of the agency. None of the following | 22 |
| may serve as a witness to the signing of a health care agency: | 23 |
| (a) the attending physician or mental health service | 24 |
| provider or relative of the physician or provider; |
|
|
|
HB4136 |
- 26 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| (b) an owner, operator, or relative of an owner or operator | 2 |
| of a health care facility in which the principal is a patient | 3 |
| or resident; | 4 |
| (c) a parent, sibling, descendant, or any spouse of such | 5 |
| parent, sibling, or descendant of either the principal or any | 6 |
| agent or successor agent, whether such relationship is by | 7 |
| blood, marriage, or adoption; or | 8 |
| (d) any agent or successor agent.
| 9 |
| (755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10)
| 10 |
| Sec. 4-10. Statutory short form power of attorney for | 11 |
| health care.
| 12 |
| (a) The following form (sometimes also referred to in this | 13 |
| Act as the
"statutory health care power") may be used to grant | 14 |
| an agent powers with
respect to the principal's own health | 15 |
| care; but the statutory health care
power is not intended to be | 16 |
| exclusive nor to cover delegation of a parent's
power to | 17 |
| control the health care of a minor child, and no provision of | 18 |
| this
Article shall be construed to invalidate or bar use by the | 19 |
| principal of any
other or
different form of power of attorney | 20 |
| for health care. Nonstatutory health
care powers must be
| 21 |
| executed by the principal, designate the agent and the agent's | 22 |
| powers, and
comply with Section 4-5 of this Article, but they | 23 |
| need not be witnessed or
conform in any other respect to the | 24 |
| statutory health care power. When a
power of attorney in | 25 |
| substantially the
following form is used, including the |
|
|
|
HB4136 |
- 27 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| "notice" paragraph at the beginning of the form on a separate | 2 |
| sheet in 14-point type
in capital letters , it shall have the | 3 |
| meaning and effect prescribed in this
Act. Such a document | 4 |
| shall be deemed to be in substantially the same format as the | 5 |
| statutory form if the explanatory language throughout the | 6 |
| document is distinguished in some way from the legal paragraphs | 7 |
| in the form, such as italicization or other difference in type | 8 |
| face or point size, if the "notice" paragraphs are not on a | 9 |
| separate sheet or not in 14-point type, or if the principal's | 10 |
| initials do not appear on the acknowledgment at the end of the | 11 |
| "notice" paragraphs. The statutory health care power may be | 12 |
| included in or
combined with any
other form of power of | 13 |
| attorney governing property or other matters.
| 14 |
| NOTICE TO THE INDIVIDUAL SIGNING | 15 |
| THE ILLINOIS STATUTORY | 16 |
| SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE | 17 |
| PLEASE READ THIS NOTICE CAREFULLY. The form that you will | 18 |
| be signing is a legal document. It is governed by the Illinois | 19 |
| Power of Attorney Act. If there is anything about this form | 20 |
| that you do not understand, you should ask a lawyer to explain | 21 |
| it to you. | 22 |
| The purpose of this Power of Attorney is to give your | 23 |
| designated "agent" broad powers to make health care decisions | 24 |
| for you, including the power to require, consent to, or | 25 |
| withdraw treatment for any physical or mental condition, and to | 26 |
| admit you or discharge you from any hospital, home, or other |
|
|
|
HB4136 |
- 28 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| institution. You may name successor agents under this form, but | 2 |
| you may not name co-agents. | 3 |
| This form does not impose a duty upon your agent to make | 4 |
| such health care decisions, so it is important that you select | 5 |
| an agent who will agree to do this for you and who will make | 6 |
| those decisions as you would wish. It is also important to | 7 |
| select an agent whom you trust, since you are giving that agent | 8 |
| control over your medical decision-making, including | 9 |
| end-of-life decisions. Any agent who does act for you has a | 10 |
| duty to use due care to act for your benefit. He or she must | 11 |
| also act in accordance with the law and with the directions in | 12 |
| this form. Your agent must keep a record of all significant | 13 |
| actions taken as your agent. | 14 |
| Unless you specifically limit the period of time that this | 15 |
| Power of Attorney will be in effect, your agent may exercise | 16 |
| the powers given to him or her throughout your lifetime, even | 17 |
| after you become disabled. A court, however, can take away the | 18 |
| powers of your agent if it finds that the agent is not acting | 19 |
| properly. You may also revoke this Power of Attorney if you | 20 |
| wish. | 21 |
| The Powers you give your agent, your right to revoke those | 22 |
| powers, and the penalties for violating the law are explained | 23 |
| more fully in Sections 4-5, 4-6 and 4-10(b) of the Illinois | 24 |
| Power of Attorney Act. This form is a part of that law. | 25 |
| You are not required to sign the Power of Attorney. You | 26 |
| should not sign it if you do not understand everything in it, |
|
|
|
HB4136 |
- 29 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| and what your agent will be able to do if you do sign it. | 2 |
| Please put your initials on the following line indicating | 3 |
| that you have read this Notice: | 4 |
| ......................
| 5 |
| (Principal's initials)"
| 6 |
| "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH | 7 |
| CARE
| 8 |
| (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE | 9 |
| THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE | 10 |
| HEALTH CARE DECISIONS FOR YOU,
INCLUDING POWER TO REQUIRE, | 11 |
| CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL
CARE OR MEDICAL | 12 |
| TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT
YOU | 13 |
| TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER | 14 |
| INSTITUTION. THIS
FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO | 15 |
| EXERCISE GRANTED POWERS; BUT
WHEN POWERS ARE EXERCISED, YOUR | 16 |
| AGENT WILL HAVE TO USE
DUE CARE TO ACT FOR
YOUR BENEFIT AND IN | 17 |
| ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF
RECEIPTS, | 18 |
| DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT
| 19 |
| CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS | 20 |
| NOT ACTING PROPERLY. YOU MAY
NAME SUCCESSOR AGENTS UNDER THIS | 21 |
| FORM
BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE | 22 |
| NAMED. UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER
IN | 23 |
| THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A | 24 |
| COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY | 25 |
| EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN | 26 |
| AFTER YOU BECOME DISABLED. THE POWERS YOU
GIVE YOUR AGENT, YOUR |
|
|
|
HB4136 |
- 30 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR
VIOLATING | 2 |
| THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND
| 3 |
| 4-10(b) OF THE ILLINOIS
"POWERS OF ATTORNEY FOR HEALTH CARE | 4 |
| LAW"
OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM). | 5 |
| THAT LAW
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF | 6 |
| POWER OF ATTORNEY YOU
MAY DESIRE. IF THERE IS ANYTHING ABOUT | 7 |
| THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER | 8 |
| TO 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)
| 14 |
| hereby appoint:
| 15 |
| ............................................................
| 16 |
| (insert name and address of agent)
| 17 |
| as my attorney-in-fact (my "agent") to act for me and in my | 18 |
| name (in any
way I could act in person) to make any and all | 19 |
| decisions for me concerning
my personal care, medical | 20 |
| treatment, hospitalization and health care and to
require, | 21 |
| withhold or withdraw any type of medical treatment or | 22 |
| procedure,
even though my death may ensue. | 23 |
| In the event that my agent fails or refuses to act, then my | 24 |
| medical provider shall be governed by my Living Will. | 25 |
| A. My agent shall have the same access to my
medical | 26 |
| records that I have, including the right to disclose the |
|
|
|
HB4136 |
- 31 - |
LRB096 11759 AJO 22527 b |
|
| 1 |
| contents
to others. My agent shall also have full power to
| 2 |
| authorize an autopsy and direct the disposition of my remains. | 3 |
| B.
Effective upon my death, my agent has the full power to | 4 |
| make an anatomical
gift of the following ( Initial initial one . | 5 |
| In the event none of the options are initialed, then it shall | 6 |
| be concluded that I do not wish to grant my agent any such | 7 |
| authority. ):
| 8 |
| ....Any organs, tissues, or eyes suitable for | 9 |
| transplantation or used for
research or education.
| 10 |
| ....Specific organs: .................................
| 11 |
| ....I do not grant my agent authority to make any | 12 |
| anatomical gifts. | 13 |
| C. My agent shall also have full power to authorize an | 14 |
| autopsy and direct the disposition of my remains. I intend for | 15 |
| this power of attorney to be in substantial compliance with | 16 |
| Section 10 of the Disposition of Remains Act, 755 ILCS 65/1 et | 17 |
| seq. All decisions made by my agent with respect to the | 18 |
| disposition of my remains, including cremation, shall be | 19 |
| binding. I hereby direct any cemetery organization, business | 20 |
| operating a crematory or columbarium or both, funeral director | 21 |
| or embalmer, or funeral establishment who receives a copy of | 22 |
| this document to act under it. | 23 |
| I intend for the person named as my agent to be treated as | 24 |
| I would be with respect to my rights regarding the use and | 25 |
| disclosure of my individually identifiable health information | 26 |
| or other medical records, including records or communications |
|
|
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LRB096 11759 AJO 22527 b |
|
| 1 |
| governed by the Mental Health and Developmental Disabilities | 2 |
| Confidentiality Act. This release authority applies to any | 3 |
| information governed by the Health Insurance Portability and | 4 |
| Accountability Act of 1996 ("HIPAA") and regulations | 5 |
| thereunder. I intend for the person named as my agent to serve | 6 |
| as my "personal representative" as that term is defined under | 7 |
| HIPAA and regulations thereunder. The person named as my agent | 8 |
| shall have the power to authorize the release of information | 9 |
| governed by HIPAA to third parties. I authorize: | 10 |
| any physician, health care professional, dentist, | 11 |
| health plan, hospital, clinic, laboratory, pharmacy or | 12 |
| other covered health care provider, any insurance company | 13 |
| and the Medical Informational Bureau, Inc., or any other | 14 |
| health care clearinghouse that has provided treatment or | 15 |
| services to me, or that has paid for or is seeking payment | 16 |
| for me for such services, | 17 |
| to give, disclose, and release to the person named as my agent, | 18 |
| without restriction, all of my individually identifiable | 19 |
| health information and medical records, regarding any past, | 20 |
| present, or future medical or mental health condition, | 21 |
| including all information relating to the diagnosis and | 22 |
| treatment of HIV/AIDS, sexually transmitted diseases, drug or | 23 |
| alcohol abuse, and mental illness (including records or | 24 |
| communications governed by the Mental Health and Developmental | 25 |
| Disabilities Confidentiality Act.) | 26 |
| The authority given to the person named as my agent shall |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| supersede any prior agreement that I may have with my health | 2 |
| care providers to restrict access to, or disclosure of, my | 3 |
| individually identifiable health information. The authority | 4 |
| given to the person named as my agent has no expiration date | 5 |
| and shall expire only in the event that I revoke the authority | 6 |
| in writing and deliver it to my health care provider. The | 7 |
| authority given to the person named as my agent to serve as my | 8 |
| "personal representative" as defined under HIPAA and | 9 |
| regulations thereunder and to access my individually | 10 |
| identifiable health information or authorize the release of the | 11 |
| same to third parties shall take effect immediately, even if I | 12 |
| designate in Paragraph 3 of this document that this agency | 13 |
| shall otherwise take effect at some future date. | 14 |
| (THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS | 15 |
| POSSIBLE SO THAT
YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY | 16 |
| DECISION YOU COULD MAKE TO
OBTAIN OR TERMINATE ANY TYPE OF | 17 |
| HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD
AND WATER AND OTHER | 18 |
| LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH
ACTION | 19 |
| WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU WISH | 20 |
| TO
LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE SPECIAL | 21 |
| RULES OR LIMIT
THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE | 22 |
| AUTOPSY OR DISPOSE OF
REMAINS, YOU MAY DO SO IN THE FOLLOWING | 23 |
| PARAGRAPHS.)
| 24 |
| 2. The powers granted above shall not include the following | 25 |
| powers or
shall be subject to the following rules or | 26 |
| limitations (here you may include
any specific limitations you |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| deem appropriate, such as: your own
definition of when | 2 |
| life-sustaining measures should be withheld; a direction
to | 3 |
| continue food and fluids or life-sustaining treatment in
all | 4 |
| events; or instructions to refuse
any specific types of | 5 |
| treatment that are inconsistent with your religious
beliefs or | 6 |
| unacceptable to you for any other reason, such as blood
| 7 |
| transfusion, electro-convulsive therapy, amputation, | 8 |
| psychosurgery,
voluntary admission to a mental institution, | 9 |
| etc.):
| 10 |
| .............................................................
| 11 |
| .............................................................
| 12 |
| .............................................................
| 13 |
| .............................................................
| 14 |
| .............................................................
| 15 |
| (THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR | 16 |
| IMPORTANCE. FOR
YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, | 17 |
| SOME GENERAL STATEMENTS
CONCERNING THE WITHHOLDING OR REMOVAL | 18 |
| OF LIFE-SUSTAINING TREATMENT ARE SET
FORTH BELOW. IF YOU AGREE | 19 |
| WITH ONE OF THESE STATEMENTS, YOU MAY
INITIAL THAT STATEMENT; | 20 |
| BUT DO NOT INITIAL MORE THAN ONE):
| 21 |
| I do not want my life to be prolonged nor do I want | 22 |
| life-sustaining
treatment to be provided or continued if my | 23 |
| agent believes the burdens of
the treatment outweigh the | 24 |
| expected benefits. I want my agent to consider
the relief of | 25 |
| suffering, the expense involved and the quality as well as
the | 26 |
| possible extension of my life in making decisions concerning
|
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| life-sustaining treatment.
| 2 |
| Initialed...........................
| 3 |
| I want my life to be prolonged and I want life-sustaining | 4 |
| treatment to be
provided or continued unless I am in a coma | 5 |
| which my attending physician
believes to be irreversible , in | 6 |
| the opinion of my attending physician, in accordance with | 7 |
| reasonable medical
standards at the time of reference , in a | 8 |
| state of "permanent unconsciousness" . If and when I am in a | 9 |
| state of "permanent unconsciousness" I have suffered
| 10 |
| irreversible coma , I want life-sustaining treatment to be | 11 |
| withheld or
discontinued. For purposes of this Section, | 12 |
| "permanent unconsciousness" shall mean a condition that, to a | 13 |
| high degree of medical certainty, (i) will last permanently, | 14 |
| without improvement, (ii) in which thought, sensation, | 15 |
| purposeful action, social interaction, and awareness of self | 16 |
| and environment are absent, and (iii) for which initiating or | 17 |
| continuing life sustaining treatment, in light of my medical | 18 |
| condition, provides only minimal medical benefit.
| 19 |
| Initialed...........................
| 20 |
| I want my life to be prolonged to the greatest extent | 21 |
| possible without
regard to my condition, the chances I have for | 22 |
| recovery or the cost of the
procedures.
| 23 |
| Initialed...........................
| 24 |
| (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE | 25 |
| MANNER
PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF | 26 |
| ATTORNEY FOR HEALTH CARE
LAW" (SEE THE BACK OF THIS FORM). YOUR |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| AGENT CAN ACT IMMEDIATELY UNLESS YOU SPECIFY OTHERWISE. ABSENT | 2 |
| AMENDMENT OR
REVOCATION, THE AUTHORITY GRANTED IN THIS
POWER OF | 3 |
| ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED
| 4 |
| AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL | 5 |
| GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A | 6 |
| LIMITATION ON THE
BEGINNING DATE OR DURATION IS MADE BY | 7 |
| INITIALING AND COMPLETING EITHER OR
BOTH OF THE FOLLOWING: )
| 8 |
| 3. ( ) This power of attorney shall become effective on
| 9 |
| .............................................................
| 10 |
| .............................................................
| 11 |
| (insert a future date or event during your lifetime, such as | 12 |
| court
determination of your disability, when you want this | 13 |
| power to first take
effect)
| 14 |
| (IF YOU DO NOT AMEND OR REVOKE THIS POWER, OR IF YOU DO NOT | 15 |
| SPECIFY A SPECIFIC ENDING DATE IN SECTION 4, IT WILL REMAIN IN | 16 |
| EFFECT UNTIL YOUR DEATH, EXCEPT THAT YOUR AGENT WILL STILL HAVE | 17 |
| THE AUTHORITY TO DONATE YOUR ORGANS, AUTHORIZE AN AUTOPSY, AND | 18 |
| DISPOSE OF YOUR REMAINS AFTER YOUR DEATH, IF YOU GRANT THAT | 19 |
| AUTHORITY TO YOUR AGENT.) | 20 |
| 4. ( ) This power of attorney shall terminate on
.......
| 21 |
| .............................................................
| 22 |
| (insert a future date or event, such as court determination of | 23 |
| your
disability, if when you want this power to terminate prior | 24 |
| to your death)
| 25 |
| ( YOU CANNOT HAVE CO-AGENTS. IF YOU WISH TO NAME SUCCESSOR | 26 |
| AGENTS, INSERT THE NAMES AND ADDRESSES OF
SUCH SUCCESSORS IN |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| THE FOLLOWING PARAGRAPH.)
| 2 |
| 5. If any agent named by me shall die, become incompetent, | 3 |
| resign,
refuse to accept the office of agent or be unavailable, | 4 |
| I name
the following (each to act alone
and successively, in | 5 |
| the order named) as successors to such agent:
| 6 |
| .............................................................
| 7 |
| .............................................................
| 8 |
| For purposes of this paragraph 5, a person shall be considered | 9 |
| to be
incompetent if and while the person is a minor or an | 10 |
| adjudicated
incompetent or disabled person or the person is | 11 |
| unable to give prompt and
intelligent consideration to health | 12 |
| care matters, as certified by a licensed physician.
(IF YOU | 13 |
| WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON,
IN THE | 14 |
| EVENT A COURT DECIDES
THAT ONE SHOULD BE APPOINTED, YOU MAY, | 15 |
| BUT ARE NOT REQUIRED TO, DO SO BY
RETAINING THE FOLLOWING
| 16 |
| PARAGRAPH. THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS | 17 |
| THAT SUCH
APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND | 18 |
| WELFARE. STRIKE OUT
PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT | 19 |
| TO ACT AS GUARDIAN.)
| 20 |
| 6. If a guardian of my person is to be appointed, I | 21 |
| nominate the agent
acting under this power of attorney as such
| 22 |
| guardian, to serve without bond or security.
| 23 |
| 7. I am fully informed as to all the contents of this form | 24 |
| and
understand the full import of this grant of powers to my | 25 |
| agent.
|
|
|
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HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| Date
| 2 |
| Signed..............................
| 3 |
| (
principal's signature or mark
principal
)
| 4 |
| The principal has had an opportunity to review read the | 5 |
| above form and has
signed the form or acknowledged his or her | 6 |
| signature or mark on the form in my presence. The undersigned | 7 |
| witness certifies that the witness is not: (a) the attending | 8 |
| physician or mental health service provider or relative of the | 9 |
| physician or provider; (b) an owner, operator, or relative of | 10 |
| an owner or operator of a health care facility in which the | 11 |
| principal is a patient or resident; (c) a parent, sibling, | 12 |
| descendant, or any spouse of such parent, sibling, or | 13 |
| descendant of either the principal or any agent or successor | 14 |
| agent under the foregoing power of attorney, whether such | 15 |
| relationship is by blood, marriage, or adoption; or (d) an | 16 |
| agent or successor agent under the foregoing power of attorney.
| |
17 | | ....................... | ...................... |
|
18 | | (Witness Signature) | (Witness Signature) |
|
19 | | ....................... | ...................... |
|
20 | | (Print Witness Name) | (Print Witness Name) |
|
21 | | ....................... | ...................... |
|
22 | | (Street Address) | (Street Address) |
|
23 | | ....................... | ...................... |
|
24 | | (City, State, ZIP) | (City, State, ZIP) |
| 25 |
| .......................... Residing at......................
| 26 |
| (witness)
|
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND | 2 |
| SUCCESSOR AGENTS
TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU | 3 |
| INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST | 4 |
| COMPLETE THE CERTIFICATION OPPOSITE THE
SIGNATURES OF THE | 5 |
| AGENTS.)
| 6 |
| Specimen signatures of I certify that the signatures of my
| 7 |
| agent (and successors). agent (and successors) are correct.
| 8 |
| ....................... ...................................
| 9 |
| (agent) (principal)
| 10 |
| ....................... ...................................
| 11 |
| (successor agent) (principal)
| 12 |
| ....................... ...................................
| 13 |
| (successor agent) (principal)"
| 14 |
| (b) The statutory short form power of attorney for health | 15 |
| care (the
"statutory health care power") authorizes the agent | 16 |
| to make any and all
health care decisions on behalf of the | 17 |
| principal which the principal could
make if present and under | 18 |
| no disability, subject to any limitations on the
granted powers | 19 |
| that appear on the face of the form, to be exercised in such
| 20 |
| manner as the agent deems consistent with the intent and | 21 |
| desires of the
principal. The agent will be under no duty to | 22 |
| exercise granted powers or
to assume control of or | 23 |
| responsibility for the principal's health care;
but when | 24 |
| granted powers are exercised, the agent will be required to use
| 25 |
| due care to act for the benefit of the principal in accordance | 26 |
| with the
terms of the statutory health care power and will be |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| liable
for negligent exercise. The agent may act in person or | 2 |
| through others
reasonably employed by the agent for that | 3 |
| purpose
but may not delegate authority to make health care | 4 |
| decisions. The agent
may sign and deliver all instruments, | 5 |
| negotiate and enter into all
agreements and do all other acts | 6 |
| reasonably necessary to implement the
exercise of the powers | 7 |
| granted to the agent. Without limiting the
generality of the | 8 |
| foregoing, the statutory health care power shall include
the | 9 |
| following powers, subject to any limitations appearing on the | 10 |
| face of the form:
| 11 |
| (1) The agent is authorized to give consent to and | 12 |
| authorize or refuse,
or to withhold or withdraw consent to, | 13 |
| any and all types of medical care,
treatment or procedures | 14 |
| relating to the physical or mental health of the
principal, | 15 |
| including any medication program, surgical procedures,
| 16 |
| life-sustaining treatment or provision of food and fluids | 17 |
| for the principal.
| 18 |
| (2) The agent is authorized to admit the principal to | 19 |
| or discharge the
principal from any and all types of | 20 |
| hospitals, institutions, homes,
residential or nursing | 21 |
| facilities, treatment centers and other health care
| 22 |
| institutions providing personal care or treatment for any | 23 |
| type of physical
or mental condition. The agent shall have | 24 |
| the same right to visit the
principal in the hospital or | 25 |
| other institution as is granted to a spouse or
adult child | 26 |
| of the principal, any rule of the institution to the |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| contrary
notwithstanding.
| 2 |
| (3) The agent is authorized to contract for any and all | 3 |
| types of health
care services and facilities in the name of | 4 |
| and on behalf of the principal
and to bind the principal to | 5 |
| pay for all such services and facilities,
and to have and | 6 |
| exercise those powers over the principal's property as are
| 7 |
| authorized under the statutory property power, to the | 8 |
| extent the agent
deems necessary to pay health care costs; | 9 |
| and
the agent shall not be personally liable for any | 10 |
| services or care contracted
for on behalf of the principal.
| 11 |
| (4) At the principal's expense and subject to | 12 |
| reasonable rules of the
health care provider to prevent | 13 |
| disruption of the principal's health care,
the agent shall | 14 |
| have the same right the principal has to examine and copy
| 15 |
| and consent to disclosure of all the principal's medical | 16 |
| records that the agent deems
relevant to the exercise of | 17 |
| the agent's powers, whether the records
relate to mental | 18 |
| health or any other medical condition and whether they are | 19 |
| in
the possession of or maintained by any physician, | 20 |
| psychiatrist,
psychologist, therapist, hospital, nursing | 21 |
| home or other health care
provider.
| 22 |
| (5) The agent is authorized: to direct that an autopsy | 23 |
| be made pursuant
to Section 2 of "An Act in relation to | 24 |
| autopsy of dead bodies", approved
August 13, 1965, | 25 |
| including all amendments;
to make a disposition of any
part | 26 |
| or all of the principal's body pursuant to the Illinois |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| Anatomical Gift
Act, as now or hereafter amended; and to | 2 |
| direct the disposition of the
principal's remains.
| 3 |
| (THE NAME, ADDRESS, AND PHONE NUMBER OF THE PERSON | 4 |
| PREPARING THIS FORM OR WHO ASSISTED THE PRINCIPAL IN COMPLETING | 5 |
| THIS FORM MAY OPTIONALLY BE INSERTED BELOW). | 6 |
| ......................... | 7 |
| (name) | 8 |
| ......................... | 9 |
| (address) | 10 |
| ......................... | 11 |
| (phone) | 12 |
| (Source: P.A. 93-794, eff. 7-22-04.)
| 13 |
| (755 ILCS 45/4-12) (from Ch. 110 1/2, par. 804-12)
| 14 |
| Sec. 4-12. Saving clause. This Act does not in any way
| 15 |
| invalidate any health care agency executed or any act of any
| 16 |
| agent done, or affect any claim, right or
remedy that accrued, | 17 |
| prior to September 22, 1987.
| 18 |
| This amendatory Act of the 96th General Assembly does not | 19 |
| in any way invalidate any health care agency executed or any | 20 |
| act of any agent done, or affect any claim, right, or remedy | 21 |
| that accrued, prior to the effective date of this amendatory | 22 |
| Act of the 96th General Assembly. |
|
|
|
HB4136 |
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LRB096 11759 AJO 22527 b |
|
| 1 |
| (Source: P.A. 86-736.)
|
|