Illinois General Assembly - Full Text of SB3228
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Full Text of SB3228  98th General Assembly

SB3228 98TH GENERAL ASSEMBLY

  
  

 


 
98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB3228

 

Introduced 2/11/2014, by Sen. William R. Haine

 

SYNOPSIS AS INTRODUCED:
 
755 ILCS 45/4-4  from Ch. 110 1/2, par. 804-4
755 ILCS 45/4-5  from Ch. 110 1/2, par. 804-5
755 ILCS 45/4-5.1
755 ILCS 45/4-10  from Ch. 110 1/2, par. 804-10

    Amends the Illinois Power of Attorney Act. Replaces the statutory short form power of attorney for health care and the notice to the individual signing the power of attorney for health care. Defines "health care agent" and deletes the definitions of "incurable or irreversible condition", "permanent unconsciousness", and "terminal condition". Changes the term "health care provider" to "health care provider" or "health care professional". Provides that no witness to the signing of a health care agency may be under 18 years of age. Provides that nonstatutory health care powers must meet certain criteria. Effective January 1, 2015.


LRB098 15174 HEP 55298 b

 

 

A BILL FOR

 

SB3228LRB098 15174 HEP 55298 b

1    AN ACT concerning civil law.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Power of Attorney Act is amended by
5changing Sections 4-4, 4-5, 4-5.1, and 4-10 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
3person.
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 a person to make health care decisions
8of any type, including, but not limited to, anatomical gift,
9autopsy, or disposition of remains for and on behalf of the
10individual. A health care agent is a personal representative
11under state and federal law, but may not be the principal's
12physician or health care provider. The health care agent has
13the authority of a personal representative under both state and
14federal law unless restricted specifically by the health care
15agency.
16    (f) (Blank). "Incurable or irreversible condition" means
17an illness or injury (i) for which there is no reasonable
18prospect of cure or recovery, (ii) that ultimately will cause
19the patient's death even if life-sustaining treatment is
20initiated or continued, (iii) that imposes severe pain or
21otherwise imposes an inhumane burden on the patient, or (iv)
22for which initiating or continuing life-sustaining treatment,
23in light of the patient's medical condition, provides only
24minimal medical benefit.
25    (g) (Blank). "Permanent unconsciousness" means a condition
26that, to a high degree of medical certainty, (i) will last

 

 

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1permanently, without improvement, (ii) in which thought,
2sensation, purposeful action, social interaction, and
3awareness of self and environment are absent, and (iii) for
4which initiating or continuing life-sustaining treatment, in
5light of the patient's medical condition, provides only minimal
6medical benefit. For the purposes of this definition, "medical
7benefit" means a chance to cure or reverse a condition.
8    (h) (Blank). "Terminal condition" means an illness or
9injury for which there is no reasonable prospect of cure or
10recovery, death is imminent, and the application of
11life-sustaining treatment would only prolong the dying
12process.
13(Source: P.A. 96-1195, eff. 7-1-11.)
 
14    (755 ILCS 45/4-5)  (from Ch. 110 1/2, par. 804-5)
15    Sec. 4-5. Limitations on health care agencies. Neither the
16attending physician nor any other health care provider or
17health care professional may act as agent under a health care
18agency; however, a person who is not administering health care
19to the patient may act as health care agent for the patient
20even though the person is a physician or otherwise licensed,
21certified, authorized, or permitted by law to administer health
22care in the ordinary course of business or the practice of a
23profession.
24(Source: P.A. 86-736.)
 

 

 

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1    (755 ILCS 45/4-5.1)
2    Sec. 4-5.1. Limitations on who may witness health care
3agencies.
4    (a) Every health care agency shall bear the signature of a
5witness to the signing of the agency. No witness may be under
618 years of age. None of the following licensed professionals
7providing services to the principal may serve as a witness to
8the signing of a health care agency:
9        (1) the attending physician, advanced practice nurse,
10    physician assistant, dentist, podiatric physician,
11    optometrist, or mental health service provider of the
12    principal, or a relative of the physician, advanced
13    practice nurse, physician assistant, dentist, podiatric
14    physician, optometrist, or mental health service provider;
15        (2) an owner, operator, or relative of an owner or
16    operator of a health care facility in which the principal
17    is a patient or resident;
18        (3) a parent, sibling, or descendant, or the spouse of
19    a parent, sibling, or descendant, of either the principal
20    or any agent or successor agent, regardless of whether the
21    relationship is by blood, marriage, or adoption;
22        (4) an agent or successor agent for health care.
23    (b) The prohibition on the operator of a health care
24facility from serving as a witness shall extend to directors
25and executive officers of an operator that is a corporate
26entity but not other employees of the operator such as, but not

 

 

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

 

 

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1shall have the meaning and effect prescribed in this Act. A
2power of attorney for health care shall be deemed to be in
3substantially the same format as the statutory form if the
4explanatory language throughout the form (the language
5following the designation "NOTE:") is distinguished in some way
6from the legal paragraphs in the form, such as the use of
7boldface or other difference in typeface and font or point
8size, even if the "Notice" paragraphs at the beginning are not
9on a separate sheet of paper or are not in 14-point type, or if
10the principal's initials do not appear in the acknowledgement
11at the end of the "Notice" paragraphs. The statutory health
12care power may be included in or combined with any other form
13of power of attorney governing property or other matters.
14    (b) The Illinois Statutory Short Form Power of Attorney for
15Health Care shall be substantially as follows:
 
16
NOTICE TO THE INDIVIDUAL SIGNING
17
THE POWER OF ATTORNEY FOR HEALTH CARE
18    No one can predict when a serious illness or accident might
19occur. When it does, you may need someone else to speak or make
20health care decisions for you. If you plan now, you can
21increase the chances that the medical treatment you get will be
22the treatment you want.
23    In Illinois, you can choose someone to be your "health care
24agent". Your agent is the person you trust to make health care
25decisions for you if you are unable or do not want to make them

 

 

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1yourself. These decisions should be based on your personal
2values and wishes.
3    It is important to put your choice of agent in writing. The
4written form is often called an "advance directive". You may
5use this form or another form, as long as it meets the legal
6requirements of Illinois. There are many written and on-line
7resources to guide you and your loved ones in having a
8conversation about these issues. You may find it helpful to
9look at these resources while thinking about and discussing
10your advance directive.
 
11
WHAT ARE THE THINGS I WANT MY
12
HEALTH CARE AGENT TO KNOW?
13    The selection of your agent should be considered carefully,
14as your agent will have the ultimate decision making authority
15once this document goes into effect, in most instances after
16you are no longer able to voice your own decisions. While the
17goal is for your agent to make decisions in keeping with your
18preferences and in the majority of circumstances that is what
19happens, please know that the law does allow your agent to make
20decisions to direct or refuse health care interventions or
21withdraw treatment. Your agent will need to think about
22conversations you have had, your personality, and how you
23handled important health care issues in the past. Therefore, it
24is important to talk with your agent and your family about such
25things as:

 

 

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1        (i) What is most important to you in your life?
2        (ii) How important is it to you to avoid pain and
3    suffering?
4        (iii) If you had to choose, is it more important to you
5    to live as long as possible, or to avoid prolonged
6    suffering or disability?
7        (iv) Would you rather be at home or in a hospital for
8    the last days or weeks of your life?
9        (v) Do you have religious, spiritual, or cultural
10    beliefs that you want your agent and others to consider?
11        (vi) Do you have an existing advanced directive, such
12    as a living will, that contains your specific wishes about
13    health care that is only delaying your death? If you have
14    another advance directive, make sure to discuss with your
15    agent the directive and the treatment decisions contained
16    within that outline your preferences. Make sure that your
17    agent agrees to honor the wishes expressed in your advance
18    directive.
 
19
WHAT KIND OF DECISIONS CAN MY AGENT MAKE?
20    If there is ever a period of time when your physician
21determines that you cannot make your own health care decisions,
22or if you do not want to make your own decisions, some of the
23decisions your agent could make are to:
24        (i) talk with physicians and other health care
25    providers about your condition.

 

 

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

 

 

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1agent will have the responsibility to make medical treatment
2decisions together with your physician and other
3professionals, even if other people close to you might urge a
4different decision. The selection of your agent should be done
5carefully, as he or she will have ultimate decision-making
6authority for your treatment decisions once you are no longer
7able to voice your preferences. Choose a family member, friend,
8or other person who:
9        (i) is at least 18 years old;
10        (ii) knows you well;
11        (iii) you trust to do what is best for you and is
12    willing to carry out your wishes, even if he or she may not
13    agree with your wishes;
14        (iv) would be comfortable talking with and questioning
15    your physicians and other health care providers;
16        (v) would not be too upset to carry out your wishes if
17    you became very sick; and
18        (vi) can be there for you when you need it and is
19    willing to accept this important role.
 
20
WHAT IF MY AGENT IS NOT AVAILABLE OR IS
21
UNWILLING TO MAKE DECISIONS FOR ME?
22    If the person who is your first choice is unable to carry
23out this role when the time comes, you can choose one or more
24successor agents. Your successor agents function as back-up
25agents to your first choice agent and may act only one at a

 

 

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1time and in the order you list them.
 
2
WHAT WILL HAPPEN IF I DO NOT
3
CHOOSE A HEALTH CARE AGENT?
4    If you become unable to make your own health care decisions
5and have not named an agent in writing, your physician and
6other health care providers will ask a family member, friend,
7or guardian to make decisions for you. In Illinois, a law
8directs which of these individuals will be consulted. In that
9law, each of these individuals is called a "surrogate".
10    There are reasons why you may want to name an agent rather
11than rely on a surrogate:
12        (i) The person or people listed by this law may not be
13    who you would want to make decisions for you.
14        (ii) Some family members or friends might not be able
15    or willing to make decisions as you would want them to.
16        (iii) Family members and friends may disagree with one
17    another about the best decisions.
18        (iv) Under some circumstances, a surrogate may not be
19    able to make the same kinds of decisions that an agent can
20    make.
 
21
WHAT IF THERE IS NO ONE AVAILABLE
22
WHOM I TRUST TO BE MY AGENT?
23    In this situation, it is especially important to talk to
24your physician and other health care providers and create

 

 

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1written guidance about what you want or do not want, in case
2you are ever critically ill and cannot express your own wishes.
3You can complete a living will. You can also write your wishes
4down and/or discuss them with your physician or other health
5care provider and ask him or her to write it down in your
6chart. You might also want to use written or on-line resources
7to guide you through this process.
 
8
WHAT DO I DO WITH THIS FORM ONCE I COMPLETE IT?
9    Follow these instructions after you have completed the
10form:
11        (i) Sign the form in front of a witness. See the form
12    for a list of who can and cannot witness it.
13        (ii) Ask the witness to sign it, too.
14        (iii) There is no need to have the form notarized.
15        (iv) Give a copy to your agent and to each of your
16    successor agents.
17        (v) Give another copy to your physician.
18        (vi) Take a copy with you when you go to the hospital.
19        (vii) Show it to your family and friends and others who
20    care for you.
 
21
WHAT IF I CHANGE MY MIND?
22    You may change your mind at any time. If you do, tell
23someone who is at least 18 years old that you have changed your
24mind, and/or destroy your document and any copies. If you wish,

 

 

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1fill out a new form and make sure everyone you gave the old
2form to has a copy of the new one.
 
3
WHAT IF I DO NOT WANT TO USE THIS FORM?
4    In the event you do not want to use the Illinois statutory
5form provided here, any document you complete must be executed
6by you, designate an agent authorized by law to serve as an
7agent, and state the agent's powers, but it need not be
8witnessed or conform in any other respect to the statutory
9health care power.
10    If you have questions about the use of any form, you may
11want to consult your physician, other health care provider,
12and/or an attorney.
 
13
MY POWER OF ATTORNEY FOR HEALTH CARE

 
14THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY
15FOR HEALTH CARE. (You must sign this form and a witness must
16also sign it before it is valid)
 
17My name (Print your full name):..............................
18My address:..................................................
 
19I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT
20(an agent is your personal representative under state and
21federal law, but your physician or health care provider cannot

 

 

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1be designated as your agent):
2(Agent name).................................................
3(Agent address)..............................................
4(Agent phone number).........................................
 
5MY AGENT CAN MAKE HEALTH CARE DECISIONS FOR ME, INCLUDING:
6        (i) Deciding to accept, withdraw or decline treatment
7    for any physical or mental condition of mine, including
8    life-and-death decisions.
9        (ii) Agreeing to admit me to or discharge me from any
10    hospital, home, or other institution, including a mental
11    health facility.
12        (iii) Having complete access to my medical and mental
13    health records, and sharing them with others as needed,
14    including after I die.
15        (iv) Carrying out the plans I have already made, or, if
16    I have not done so, making decisions about my body or
17    remains, including organ, tissue or body donation,
18    autopsy, cremation, and burial.
19    The above grant of power is intended to be as broad as
20possible so that your agent will have the authority to make any
21decision you could make to obtain or terminate any type of
22health care, including withdrawal of nutrition and hydration
23and other life-sustaining measures.
 
24I AUTHORIZE MY AGENT TO (please check any one box):

 

 

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1    .... Make decisions for me only when I cannot make them for
2    myself. The physician(s) taking care of me will determine
3    when I lack this ability.
4        (If no box is checked, then the box above shall be
5    implemented.) OR
6    .... Make decisions for me starting now and continuing
7    after I am no longer able to make them for myself. While I
8    am still able to make my own decisions, I can still do so
9    if I want to.
 
10    The subject of life-sustaining treatment is of particular
11importance. Life-sustaining treatments may include tube
12feedings or fluids through a tube, breathing machines, and CPR.
13In general, in making decisions concerning life-sustaining
14treatment, your agent is instructed to consider the relief of
15suffering, the quality as well as the possible extension of
16your life, and your previously expressed wishes. Your agent
17will weigh the burdens versus benefits of proposed treatments
18in making decisions on your behalf.
19    Additional statements concerning the withholding or
20removal of life-sustaining treatment are described below.
21These can serve as a guide for your agent when making decisions
22for you. Ask your physician or health care provider if you have
23any questions about these statements.
 
24SELECT ONLY ONE STATEMENT BELOW THAT BEST EXPRESSES YOUR WISHES

 

 

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1(optional):
2    .... The quality of my life is more important than the
3    length of my life. If I am unconscious and my attending
4    physician believes, in accordance with reasonable medical
5    standards, that I will not wake up or recover my ability to
6    think, communicate with my family and friends, and
7    experience my surroundings, I do not want treatments to
8    prolong my life.
9    .... Staying alive is more important to me, no matter how
10    sick I am, how much I am suffering, the cost of the
11    procedures, or how unlikely my chances for recovery are. I
12    want my life to be prolonged to the greatest extent
13    possible in accordance with reasonable medical standards.
 
14SPECIFIC LIMITATIONS TO MY AGENT'S DECISION-MAKING AUTHORITY:
15    The above grant of power is intended to be as broad as
16possible so that your agent will have the authority to make any
17decision you could make to obtain or terminate any type of
18health care. If you wish to limit the scope of your agent's
19powers or prescribe special rules or limit the power to
20authorize autopsy or dispose of remains, you may do so
21specifically in this form.
22.............................................................
23.............................................................
 
24My signature:................................................

 

 

SB3228- 17 -LRB098 15174 HEP 55298 b

1Today's date:................................................
 
2HAVE YOUR WITNESS AGREE TO WHAT IS WRITTEN BELOW, AND THEN
3COMPLETE THE SIGNATURE PORTION:
4    I am at least 18 years old. (check one of the options
5below):
6    .... I saw the principal sign this document, or
7    .... the principal told me that the signature or mark on
8    the principal signature line is his or hers.
9    I am not the agent or successor agent(s) named in this
10document. I am not related to the principal, the agent, or the
11successor agent(s) by blood, marriage, or adoption. I am not
12the principal's physician, mental health service provider, or a
13relative of one of those individuals. I am not an owner or
14operator (or the relative of an owner or operator) of the
15health care facility where the principal is a patient or
16resident.
17Witness printed name:........................................
18Witness address:.............................................
19Witness signature:...........................................
20Today's date:................................................
 
21SUCCESSOR HEALTH CARE AGENT(S) (optional):
22    If the agent I selected is unable or does not want to make
23health care decisions for me, then I request the person(s) I
24name below to be my successor health care agent(s). Only one

 

 

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1person at a time can serve as my agent (add another page if you
2want to add more successor agent names):
3.............................................................
4(Successor agent #1 name, address and phone number)
5.............................................................
6(Successor agent #2 name, address and phone number)
 
7
"NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS
8
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE

 
9    PLEASE READ THIS NOTICE CAREFULLY. The form that you will
10be signing is a legal document. It is governed by the Illinois
11Power of Attorney Act. If there is anything about this form
12that you do not understand, you should ask a lawyer to explain
13it to you.
14    The purpose of this Power of Attorney is to give your
15designated "agent" broad powers to make health care decisions
16for you, including the power to require, consent to, or
17withdraw treatment for any physical or mental condition, and to
18admit you or discharge you from any hospital, home, or other
19institution. You may name successor agents under this form, but
20you may not name co-agents.
21    This form does not impose a duty upon your agent to make
22such health care decisions, so it is important that you select
23an agent who will agree to do this for you and who will make
24those decisions as you would wish. It is also important to

 

 

SB3228- 19 -LRB098 15174 HEP 55298 b

1select an agent whom you trust, since you are giving that agent
2control over your medical decision-making, including
3end-of-life decisions. Any agent who does act for you has a
4duty to act in good faith for your benefit and to use due care,
5competence, and diligence. He or she must also act in
6accordance with the law and with the statements in this form.
7Your agent must keep a record of all significant actions taken
8as your agent.
9    Unless you specifically limit the period of time that this
10Power of Attorney will be in effect, your agent may exercise
11the powers given to him or her throughout your lifetime, even
12after you become disabled. A court, however, can take away the
13powers of your agent if it finds that the agent is not acting
14properly. You may also revoke this Power of Attorney if you
15wish.
16    The Powers you give your agent, your right to revoke those
17powers, and the penalties for violating the law are explained
18more fully in Sections 4-5, 4-6, and 4-10(c) of the Illinois
19Power of Attorney Act. This form is a part of that law. The
20"NOTE" paragraphs throughout this form are instructions.
21    You are not required to sign this Power of Attorney, but it
22will not take effect without your signature. You should not
23sign it if you do not understand everything in it, and what
24your agent will be able to do if you do sign it.
 
25    Please put your initials on the following line indicating

 

 

SB3228- 20 -LRB098 15174 HEP 55298 b

1that you have read this Notice:
2
......................
3
(Principal's initials)"

 
4
"ILLINOIS STATUTORY SHORT FORM
5
POWER OF ATTORNEY FOR HEALTH CARE

 
6    1. I, ..................................................,
7(insert name and address of principal) hereby revoke all prior
8powers of attorney for health care executed by me and appoint:
9............................................................
10(insert name and address of agent)
11(NOTE: You may not name co-agents using this form.)
12as my attorney-in-fact (my "agent") to act for me and in my
13name (in any way I could act in person) to make any and all
14decisions for me concerning my personal care, medical
15treatment, hospitalization and health care and to require,
16withhold or withdraw any type of medical treatment or
17procedure, even though my death may ensue.
18    A. My agent shall have the same access to my medical
19records that I have, including the right to disclose the
20contents to others.
21    B. Effective upon my death, my agent has the full power to
22make an anatomical gift of the following:
23(NOTE: Initial one. In the event none of the options are
24initialed, then it shall be concluded that you do not wish to

 

 

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1grant your agent any such authority.)
2        .... Any organs, tissues, or eyes suitable for
3    transplantation or used for research or education.
4        .... Specific organs:................................
5        .... I do not grant my agent authority to make any
6    anatomical gifts.
7    C. My agent shall also have full power to authorize an
8autopsy and direct the disposition of my remains. I intend for
9this power of attorney to be in substantial compliance with
10Section 10 of the Disposition of Remains Act. All decisions
11made by my agent with respect to the disposition of my remains,
12including cremation, shall be binding. I hereby direct any
13cemetery organization, business operating a crematory or
14columbarium or both, funeral director or embalmer, or funeral
15establishment who receives a copy of this document to act under
16it.
17    D. I intend for the person named as my agent to be treated
18as I would be with respect to my rights regarding the use and
19disclosure of my individually identifiable health information
20or other medical records, including records or communications
21governed by the Mental Health and Developmental Disabilities
22Confidentiality Act. This release authority applies to any
23information governed by the Health Insurance Portability and
24Accountability Act of 1996 ("HIPAA") and regulations
25thereunder. I intend for the person named as my agent to serve
26as my "personal representative" as that term is defined under

 

 

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1HIPAA and regulations thereunder.
2    (i) The person named as my agent shall have the power to
3authorize the release of information governed by HIPAA to third
4parties.
5    (ii) I authorize any physician, health care professional,
6dentist, health plan, hospital, clinic, laboratory, pharmacy
7or other covered health care provider, any insurance company
8and the Medical Informational Bureau, Inc., or any other health
9care clearinghouse that has provided treatment or services to
10me, or that has paid for or is seeking payment for me for such
11services to give, disclose, and release to the person named as
12my agent, without restriction, all of my individually
13identifiable health information and medical records, regarding
14any past, present, or future medical or mental health
15condition, including all information relating to the diagnosis
16and treatment of HIV/AIDS, sexually transmitted diseases, drug
17or alcohol abuse, and mental illness (including records or
18communications governed by the Mental Health and Developmental
19Disabilities Confidentiality Act).
20    (iii) The authority given to the person named as my agent
21shall supersede any prior agreement that I may have with my
22health care providers to restrict access to, or disclosure of,
23my individually identifiable health information. The authority
24given to the person named as my agent has no expiration date
25and shall expire only in the event that I revoke the authority
26in writing and deliver it to my health care provider.

 

 

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

 

 

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

 

 

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

 

 

SB3228- 26 -LRB098 15174 HEP 55298 b

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

 

 

SB3228- 27 -LRB098 15174 HEP 55298 b

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

 

 

SB3228- 28 -LRB098 15174 HEP 55298 b

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

 

 

SB3228- 29 -LRB098 15174 HEP 55298 b

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

 

 

SB3228- 30 -LRB098 15174 HEP 55298 b

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

 

 

SB3228- 31 -LRB098 15174 HEP 55298 b

1        (4) At the principal's expense and subject to
2    reasonable rules of the health care provider to prevent
3    disruption of the principal's health care, the agent shall
4    have the same right the principal has to examine and copy
5    and consent to disclosure of all the principal's medical
6    records that the agent deems relevant to the exercise of
7    the agent's powers, whether the records relate to mental
8    health or any other medical condition and whether they are
9    in the possession of or maintained by any physician,
10    psychiatrist, psychologist, therapist, hospital, nursing
11    home or other health care provider.
12        (5) The agent is authorized: to direct that an autopsy
13    be made pursuant to Section 2 of "An Act in relation to
14    autopsy of dead bodies", approved August 13, 1965,
15    including all amendments; to make a disposition of any part
16    or all of the principal's body pursuant to the Illinois
17    Anatomical Gift Act, as now or hereafter amended; and to
18    direct the disposition of the principal's remains.
19(Source: P.A. 96-1195, eff. 7-1-11; 97-148, eff. 7-14-11.)
 
20    Section 99. Effective date. This Act takes effect January
211, 2015.