Full Text of SB3228 98th General Assembly
SB3228eng 98TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning civil law.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Power of Attorney Act is amended by | 5 | | changing Sections 4-4, 4-5, 4-5.1, 4-10, and 4-12 as follows:
| 6 | | (755 ILCS 45/4-4) (from Ch. 110 1/2, par. 804-4)
| 7 | | Sec. 4-4. Definitions. As used in this Article:
| 8 | | (a) "Attending physician" means the physician who has | 9 | | primary
responsibility at the time of reference for the | 10 | | treatment and care of the patient.
| 11 | | (b) "Health care" means any care, treatment, service or | 12 | | procedure to
maintain, diagnose, treat or provide for the | 13 | | patient's physical or mental
health or personal care.
| 14 | | (c) "Health care agency" means an agency governing any type | 15 | | of health
care, anatomical gift, autopsy or disposition of | 16 | | remains for and on behalf
of a patient and refers to the power | 17 | | of attorney or other written
instrument defining the agency or | 18 | | the 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 | 21 | | administering health care to the patient at the time
of | 22 | | reference who is licensed, certified, or otherwise authorized | 23 | | or
permitted by law to administer health care in the ordinary |
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| 1 | | course of
business or the practice of a profession, including | 2 | | any person employed by
or acting for any such authorized | 3 | | person.
| 4 | | (e) "Patient" means the principal or, if the agency governs | 5 | | health care
for a minor child of the principal, then the child.
| 6 | | (e-5) "Health care agent" means an individual at least 18 | 7 | | years old designated by a person to make health care decisions | 8 | | of any type, including, but not limited to, anatomical gift, | 9 | | autopsy, or disposition of remains for and on behalf of the | 10 | | individual. A health care agent is a personal representative | 11 | | under state and federal law, but may not be the principal's | 12 | | physician or health care provider. The health care agent has | 13 | | the authority of a personal representative under both state and | 14 | | federal law unless restricted specifically by the health care | 15 | | agency. | 16 | | (f) (Blank). "Incurable or irreversible condition" means | 17 | | an illness or injury (i) for which there is no reasonable | 18 | | prospect of cure or recovery, (ii) that ultimately will cause | 19 | | the patient's death even if life-sustaining treatment is | 20 | | initiated or continued, (iii) that imposes severe pain or | 21 | | otherwise imposes an inhumane burden on the patient, or (iv) | 22 | | for which initiating or continuing life-sustaining treatment, | 23 | | in light of the patient's medical condition, provides only | 24 | | minimal medical benefit. | 25 | | (g) (Blank). "Permanent unconsciousness" means a condition | 26 | | that, to a high degree of medical certainty, (i) will last |
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| 1 | | permanently, without improvement, (ii) in which thought, | 2 | | sensation, purposeful action, social interaction, and | 3 | | awareness of self and environment are absent, and (iii) for | 4 | | which initiating or continuing life-sustaining treatment, in | 5 | | light of the patient's medical condition, provides only minimal | 6 | | medical benefit. For the purposes of this definition, "medical | 7 | | benefit" means a chance to cure or reverse a condition. | 8 | | (h) (Blank). "Terminal condition" means an illness or | 9 | | injury for which there is no reasonable prospect of cure or | 10 | | recovery, death is imminent, and the application of | 11 | | life-sustaining treatment would only prolong the dying | 12 | | process. | 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 | 16 | | attending
physician nor any other health care provider or | 17 | | health care professional may act as agent under a
health care | 18 | | agency; however, a person who is not administering health
care | 19 | | to the patient may act as health care agent for the patient | 20 | | even
though the person is a physician or otherwise licensed, | 21 | | certified,
authorized, or permitted by law to administer health | 22 | | care in the ordinary
course of business or the practice of a | 23 | | profession.
| 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 | 3 | | agencies. | 4 | | (a) Every health care agency shall bear the signature of a | 5 | | witness to the signing of the agency. No witness may be under | 6 | | 18 years of age. None of the following licensed professionals | 7 | | providing services to the principal may serve as a witness to | 8 | | the 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 | 24 | | facility from serving as a witness shall extend to directors | 25 | | and executive officers of an operator that is a corporate | 26 | | entity but not other employees of the operator such as, but not |
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| 1 | | limited to, non-owner chaplains or social workers, nurses, and | 2 | | other 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 | 6 | | health care.
| 7 | | (a) The form prescribed in this Section (sometimes also | 8 | | referred to in this Act as the
"statutory health care power") | 9 | | may be used to grant an agent powers with
respect to the | 10 | | principal's own health care; but the statutory health care
| 11 | | power is not intended to be exclusive nor to cover delegation | 12 | | of a parent's
power to control the health care of a minor | 13 | | child, and no provision of this
Article shall be construed to | 14 | | invalidate or bar use by the principal of any
other or
| 15 | | different form of power of attorney for health care. | 16 | | Nonstatutory health
care powers must be
executed by the | 17 | | principal, designate the agent and the agent's powers, and
| 18 | | comply with the limitations in Section 4-5 of this Article, but | 19 | | they need not be witnessed or
conform in any other respect to | 20 | | the statutory health care power. | 21 | | When a
power of attorney in substantially the
form | 22 | | prescribed in this Section is used, including the "Notice to | 23 | | the Individual Signing the Illinois Statutory Short Form Power | 24 | | of Attorney for Health Care" (or "Notice" paragraphs) at the | 25 | | beginning of the form on a separate sheet in 14-point type, it |
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| 1 | | shall have the meaning and effect prescribed in this
Act. A | 2 | | power of attorney for health care shall be deemed to be in | 3 | | substantially the same format as the statutory form if the | 4 | | explanatory language throughout the form (the language | 5 | | following the designation "NOTE:") is distinguished in some way | 6 | | from the legal paragraphs in the form, such as the use of | 7 | | boldface or other difference in typeface and font or point | 8 | | size, even if the "Notice" paragraphs at the beginning are not | 9 | | on a separate sheet of paper or are not in 14-point type, or if | 10 | | the principal's initials do not appear in the acknowledgement | 11 | | at the end of the "Notice" paragraphs. The statutory health | 12 | | care power may be included in or
combined with any
other form | 13 | | of power of attorney governing property or other matters.
| 14 | | (b) The Illinois Statutory Short Form Power of Attorney for | 15 | | Health 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 | 19 | | occur. When it does, you may need someone else to speak or make | 20 | | health care decisions for you. If you plan now, you can | 21 | | increase the chances that the medical treatment you get will be | 22 | | the treatment you want. | 23 | | In Illinois, you can choose someone to be your "health care | 24 | | agent". Your agent is the person you trust to make health care | 25 | | decisions for you if you are unable or do not want to make them |
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| 1 | | yourself. These decisions should be based on your personal | 2 | | values and wishes. | 3 | | It is important to put your choice of agent in writing. The | 4 | | written form is often called an "advance directive". You may | 5 | | use this form or another form, as long as it meets the legal | 6 | | requirements of Illinois. There are many written and on-line | 7 | | resources to guide you and your loved ones in having a | 8 | | conversation about these issues. You may find it helpful to | 9 | | look at these resources while thinking about and discussing | 10 | | your 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, | 14 | | as your agent will have the ultimate decision making authority | 15 | | once this document goes into effect, in most instances after | 16 | | you are no longer able to voice your own decisions. While the | 17 | | goal is for your agent to make decisions in keeping with your | 18 | | preferences and in the majority of circumstances that is what | 19 | | happens, please know that the law does allow your agent to make | 20 | | decisions to direct or refuse health care interventions or | 21 | | withdraw treatment. Your agent will need to think about | 22 | | conversations you have had, your personality, and how you | 23 | | handled important health care issues in the past. Therefore, it | 24 | | is important to talk with your agent and your family about such | 25 | | things 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 | 21 | | determines that you cannot make your own health care decisions, | 22 | | or if you do not want to make your own decisions, some of the | 23 | | decisions 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 | 23 | | care 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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| 1 | | agent will have the responsibility to make medical treatment | 2 | | decisions together with your physician and other | 3 | | professionals, even if other people close to you might urge a | 4 | | different decision. The selection of your agent should be done | 5 | | carefully, as he or she will have ultimate decision-making | 6 | | authority for your treatment decisions once you are no longer | 7 | | able to voice your preferences. Choose a family member, friend, | 8 | | or 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 | 23 | | out this role when the time comes, you can choose one or more | 24 | | successor agents. Your successor agents function as back-up | 25 | | agents to your first choice agent and may act only one at a |
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| 1 | | time 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 | 5 | | and have not named an agent in writing, your physician and | 6 | | other health care providers will ask a family member, friend, | 7 | | or guardian to make decisions for you. In Illinois, a law | 8 | | directs which of these individuals will be consulted. In that | 9 | | law, each of these individuals is called a "surrogate". | 10 | | There are reasons why you may want to name an agent rather | 11 | | than 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 | 24 | | your physician and other health care providers and create |
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| 1 | | written guidance about what you want or do not want, in case | 2 | | you are ever critically ill and cannot express your own wishes. | 3 | | You can complete a living will. You can also write your wishes | 4 | | down and/or discuss them with your physician or other health | 5 | | care provider and ask him or her to write it down in your | 6 | | chart. You might also want to use written or on-line resources | 7 | | to 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 | 10 | | form: | 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 | 23 | | someone who is at least 18 years old that you have changed your | 24 | | mind, and/or destroy your document and any copies. If you wish, |
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| 1 | | fill out a new form and make sure everyone you gave the old | 2 | | form 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 | 5 | | form provided here, any document you complete must be executed | 6 | | by you, designate an agent authorized by law to serve as an | 7 | | agent, and state the agent's powers, but it need not be | 8 | | witnessed or conform in any other respect to the statutory | 9 | | health care power. | 10 | | If you have questions about the use of any form, you may | 11 | | want to consult your physician, other health care provider, | 12 | | and/or an attorney. | 13 | | MY POWER OF ATTORNEY FOR HEALTH CARE | 14 | | THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY | 15 | | FOR HEALTH CARE. (You must sign this form and a witness must | 16 | | also sign it before it is valid) | 17 | | My name (Print your full name): .............................. | 18 | | My address: .................................................. | 19 | | I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT | 20 | | (an agent is your personal representative under state and | 21 | | federal law, but your physician or health care provider cannot |
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| 1 | | be designated as your agent): | 2 | | (Agent name) ................................................. | 3 | | (Agent address) .............................................. | 4 | | (Agent phone number) ......................................... | 5 | | MY 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 | 20 | | possible so that your agent will have the authority to make any | 21 | | decision you could make to obtain or terminate any type of | 22 | | health care, including withdrawal of nutrition and hydration | 23 | | and other life-sustaining measures. | 24 | | I 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 | 11 | | importance. Life-sustaining treatments may include tube | 12 | | feedings or fluids through a tube, breathing machines, and CPR. | 13 | | In general, in making decisions concerning life-sustaining | 14 | | treatment, your agent is instructed to consider the relief of | 15 | | suffering, the quality as well as the possible extension of | 16 | | your life, and your previously expressed wishes. Your agent | 17 | | will weigh the burdens versus benefits of proposed treatments | 18 | | in making decisions on your behalf. | 19 | | Additional statements concerning the withholding or | 20 | | removal of life-sustaining treatment are described below. | 21 | | These can serve as a guide for your agent when making decisions | 22 | | for you. Ask your physician or health care provider if you have | 23 | | any questions about these statements. | 24 | | SELECT 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. | 14 | | SPECIFIC LIMITATIONS TO MY AGENT'S DECISION-MAKING AUTHORITY: | 15 | | The above grant of power is intended to be as broad as | 16 | | possible so that your agent will have the authority to make any | 17 | | decision you could make to obtain or terminate any type of | 18 | | health care. If you wish to limit the scope of your agent's | 19 | | powers or prescribe special rules or limit the power to | 20 | | authorize autopsy or dispose of remains, you may do so | 21 | | specifically in this form. | 22 | | ............................................................. | 23 | | ............................................................. | 24 | | My signature: ................................................ |
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| 1 | | Today's date: ................................................ | 2 | | HAVE YOUR WITNESS AGREE TO WHAT IS WRITTEN BELOW, AND THEN | 3 | | COMPLETE THE SIGNATURE PORTION: | 4 | | I am at least 18 years old. (check one of the options | 5 | | below): | 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 | 10 | | document. I am not related to the principal, the agent, or the | 11 | | successor agent(s) by blood, marriage, or adoption. I am not | 12 | | the principal's physician, mental health service provider, or a | 13 | | relative of one of those individuals. I am not an owner or | 14 | | operator (or the relative of an owner or operator) of the | 15 | | health care facility where the principal is a patient or | 16 | | resident. | 17 | | Witness printed name: ........................................ | 18 | | Witness address: ............................................. | 19 | | Witness signature: ........................................... | 20 | | Today's date: ................................................ | 21 | | SUCCESSOR HEALTH CARE AGENT(S) (optional): | 22 | | If the agent I selected is unable or does not want to make | 23 | | health care decisions for me, then I request the person(s) I | 24 | | name below to be my successor health care agent(s). Only one |
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| 1 | | person at a time can serve as my agent (add another page if you | 2 | | want 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 | 10 | | be signing is a legal document. It is governed by the Illinois | 11 | | Power of Attorney Act. If there is anything about this form | 12 | | that you do not understand, you should ask a lawyer to explain | 13 | | it to you. | 14 | | The purpose of this Power of Attorney is to give your | 15 | | designated "agent" broad powers to make health care decisions | 16 | | for you, including the power to require, consent to, or | 17 | | withdraw treatment for any physical or mental condition, and to | 18 | | admit you or discharge you from any hospital, home, or other | 19 | | institution. You may name successor agents under this form, but | 20 | | you may not name co-agents. | 21 | | This form does not impose a duty upon your agent to make | 22 | | such health care decisions, so it is important that you select | 23 | | an agent who will agree to do this for you and who will make | 24 | | those decisions as you would wish. It is also important to |
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| 1 | | select an agent whom you trust, since you are giving that agent | 2 | | control over your medical decision-making, including | 3 | | end-of-life decisions. Any agent who does act for you has a | 4 | | duty to act in good faith for your benefit and to use due care, | 5 | | competence, and diligence. He or she must also act in | 6 | | accordance with the law and with the statements in this form. | 7 | | Your agent must keep a record of all significant actions taken | 8 | | as your agent. | 9 | | Unless you specifically limit the period of time that this | 10 | | Power of Attorney will be in effect, your agent may exercise | 11 | | the powers given to him or her throughout your lifetime, even | 12 | | after you become disabled. A court, however, can take away the | 13 | | powers of your agent if it finds that the agent is not acting | 14 | | properly. You may also revoke this Power of Attorney if you | 15 | | wish. | 16 | | The Powers you give your agent, your right to revoke those | 17 | | powers, and the penalties for violating the law are explained | 18 | | more fully in Sections 4-5, 4-6, and 4-10(c) of the Illinois | 19 | | Power 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 | 22 | | will not take effect without your signature. You should not | 23 | | sign it if you do not understand everything in it, and what | 24 | | your agent will be able to do if you do sign it. | 25 | | Please put your initials on the following line indicating |
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| 1 | | that 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 | 8 | | powers 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.) | 12 | | as my attorney-in-fact (my "agent") to act for me and in my | 13 | | name (in any
way I could act in person) to make any and all | 14 | | decisions for me concerning
my personal care, medical | 15 | | treatment, hospitalization and health care and to
require, | 16 | | withhold or withdraw any type of medical treatment or | 17 | | procedure,
even though my death may ensue. | 18 | | A. My agent shall have the same access to my
medical | 19 | | records that I have, including the right to disclose the | 20 | | contents
to others. | 21 | | B.
Effective upon my death, my agent has the full power to | 22 | | make an anatomical
gift of the following: | 23 | | (NOTE: Initial one. In the event none of the options are | 24 | | initialed, then it shall be concluded that you do not wish to |
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| 1 | | grant 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 | 8 | | autopsy and direct the disposition of my remains. I intend for | 9 | | this power of attorney to be in substantial compliance with | 10 | | Section 10 of the Disposition of Remains Act. All decisions | 11 | | made by my agent with respect to the disposition of my remains, | 12 | | including cremation, shall be binding. I hereby direct any | 13 | | cemetery organization, business operating a crematory or | 14 | | columbarium or both, funeral director or embalmer, or funeral | 15 | | establishment who receives a copy of this document to act under | 16 | | it. | 17 | | D. I intend for the person named as my agent to be treated | 18 | | as I would be with respect to my rights regarding the use and | 19 | | disclosure of my individually identifiable health information | 20 | | or other medical records, including records or communications | 21 | | governed by the Mental Health and Developmental Disabilities | 22 | | Confidentiality Act. This release authority applies to any | 23 | | information governed by the Health Insurance Portability and | 24 | | Accountability Act of 1996 ("HIPAA") and regulations | 25 | | thereunder. I intend for the person named as my agent to serve | 26 | | as my "personal representative" as that term is defined under |
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| 1 | | HIPAA and regulations thereunder. | 2 | | (i) The person named as my agent shall have the power to | 3 | | authorize the release of information governed by HIPAA to third | 4 | | parties. | 5 | | (ii) I authorize any physician, health care professional, | 6 | | dentist, health plan, hospital, clinic, laboratory, pharmacy | 7 | | or other covered health care provider, any insurance company | 8 | | and the Medical Informational Bureau, Inc., or any other health | 9 | | care clearinghouse that has provided treatment or services to | 10 | | me, or that has paid for or is seeking payment for me for such | 11 | | services to give, disclose, and release to the person named as | 12 | | my agent, without restriction, all of my individually | 13 | | identifiable health information and medical records, regarding | 14 | | any past, present, or future medical or mental health | 15 | | condition, including all information relating to the diagnosis | 16 | | and treatment of HIV/AIDS, sexually transmitted diseases, drug | 17 | | or alcohol abuse, and mental illness (including records or | 18 | | communications governed by the Mental Health and Developmental | 19 | | Disabilities Confidentiality Act). | 20 | | (iii) The authority given to the person named as my agent | 21 | | shall supersede any prior agreement that I may have with my | 22 | | health care providers to restrict access to, or disclosure of, | 23 | | my individually identifiable health information. The authority | 24 | | given to the person named as my agent has no expiration date | 25 | | and shall expire only in the event that I revoke the authority | 26 | | in 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 | 2 | | possible so that your agent will have the authority to make any | 3 | | decision you could make to obtain or terminate any type of | 4 | | health care, including withdrawal of food and water and other | 5 | | life-sustaining measures, if your agent believes such action | 6 | | would be consistent with your intent and desires. If you wish | 7 | | to limit the scope of your agent's powers or prescribe special | 8 | | rules or limit the power to make an anatomical gift, authorize | 9 | | autopsy or dispose of remains, you may do so in the following | 10 | | paragraphs.)
| 11 | | 2. The powers granted above shall not include the following | 12 | | powers or
shall be subject to the following rules or | 13 | | limitations: | 14 | | (NOTE: Here you may include
any specific limitations you deem | 15 | | appropriate, such as: your own
definition of when | 16 | | life-sustaining measures should be withheld; a direction
to | 17 | | continue food and fluids or life-sustaining treatment in
all | 18 | | events; or instructions to refuse
any specific types of | 19 | | treatment that are inconsistent with your religious
beliefs or | 20 | | unacceptable to you for any other reason, such as blood
| 21 | | transfusion, electro-convulsive therapy, amputation, | 22 | | psychosurgery,
voluntary admission to a mental institution, | 23 | | etc.)
| 24 | | .............................................................
| 25 | | .............................................................
| 26 | | .............................................................
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| 1 | | .............................................................
| 2 | | .............................................................
| 3 | | (NOTE: The subject of life-sustaining treatment is of | 4 | | particular importance. For your convenience in dealing with | 5 | | that subject, some general statements concerning the | 6 | | withholding or removal of life-sustaining treatment are set | 7 | | forth below. If you agree with one of these statements, you may | 8 | | initial that statement; but do not initial more than one. These | 9 | | statements serve as guidance for your agent, who shall give | 10 | | careful consideration to the statement you initial when | 11 | | engaging in health care decision-making on your behalf.)
| 12 | | I do not want my life to be prolonged nor do I want | 13 | | life-sustaining
treatment to be provided or continued if my | 14 | | agent believes the burdens of
the treatment outweigh the | 15 | | expected benefits. I want my agent to consider
the relief of | 16 | | suffering, the expense involved and the quality as well as
the | 17 | | possible extension of my life in making decisions concerning
| 18 | | life-sustaining treatment.
| 19 | | Initialed ...........................
| 20 | | I want my life to be prolonged and I want life-sustaining | 21 | | treatment to be
provided or continued, unless I am, in the | 22 | | opinion of my attending physician, in accordance with | 23 | | reasonable medical
standards at the time of reference, in a | 24 | | state of "permanent unconsciousness" or suffer from an | 25 | | "incurable or irreversible condition" or "terminal condition", | 26 | | as those terms are defined in Section 4-4 of the Illinois Power |
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| 1 | | of Attorney Act. If and when I am in any one of these states or | 2 | | conditions, I want life-sustaining treatment to be withheld or
| 3 | | discontinued.
| 4 | | Initialed ...........................
| 5 | | I want my life to be prolonged to the greatest extent | 6 | | possible in accordance with reasonable medical standards | 7 | | without
regard to my condition, the chances I have for recovery | 8 | | or the cost of the
procedures.
| 9 | | Initialed ...........................
| 10 | | (NOTE: This power of attorney may be amended or revoked by you | 11 | | in the manner provided in Section 4-6 of the Illinois Power of | 12 | | Attorney 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 | 17 | | as a court
determination of your disability or a written | 18 | | determination by your physician that you are incapacitated, | 19 | | when you want this power to first take
effect.)
| 20 | | (NOTE: If you do not amend or revoke this power, or if you do | 21 | | not specify a specific ending date in paragraph 4, it will | 22 | | remain in effect until your death; except that your agent will | 23 | | still have the authority to donate your organs, authorize an | 24 | | autopsy, and dispose of your remains after your death, if you | 25 | | grant that authority to your agent.) | 26 | | 4. This power of attorney shall terminate on
..........
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| 1 | | .............................................................
| 2 | | (NOTE: Insert a future date or event, such as a court | 3 | | determination that you are not under a legal disability or a | 4 | | written determination by your physician that you are not | 5 | | incapacitated, if you want this power to terminate prior to | 6 | | your death.)
| 7 | | (NOTE: You cannot use this form to name co-agents. If you wish | 8 | | to name successor agents, insert the names and addresses of the | 9 | | successors in paragraph 5.)
| 10 | | 5. If any agent named by me shall die, become incompetent, | 11 | | resign,
refuse to accept the office of agent or be unavailable, | 12 | | I name
the following (each to act alone
and successively, in | 13 | | the order named) as successors to such agent:
| 14 | | .............................................................
| 15 | | .............................................................
| 16 | | For purposes of this paragraph 5, a person shall be considered | 17 | | to be
incompetent if and while the person is a minor, or an | 18 | | adjudicated
incompetent or disabled person, or the person is | 19 | | unable to give prompt and
intelligent consideration to health | 20 | | care matters, as certified by a licensed physician.
| 21 | | (NOTE: If you wish to, you may name your agent as guardian of | 22 | | your person if a court decides that one should be appointed. To | 23 | | do this, retain paragraph 6, and the court will appoint your | 24 | | agent if the court finds that this appointment will serve your | 25 | | best interests and welfare. Strike out paragraph 6 if you do | 26 | | not want your agent to act as guardian.)
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| 1 | | 6. If a guardian of my person is to be appointed, I | 2 | | nominate the agent
acting under this power of attorney as such
| 3 | | guardian, to serve without bond or security.
| 4 | | 7. I am fully informed as to all the contents of this form | 5 | | and
understand the full import of this grant of powers to my | 6 | | agent.
| 7 | | Dated: ..........
| 8 | | Signed ..............................
| 9 | | (principal's signature or mark)
| 10 | | The principal has had an opportunity to review the above | 11 | | form and has
signed the form or acknowledged his or her | 12 | | signature or mark on the form in my presence. The undersigned | 13 | | witness certifies that the witness is not: (a) the attending | 14 | | physician or mental health service provider or a relative of | 15 | | the physician or provider; (b) an owner, operator, or relative | 16 | | of an owner or operator of a health care facility in which the | 17 | | principal is a patient or resident; (c) a parent, sibling, | 18 | | descendant, or any spouse of such parent, sibling, or | 19 | | descendant of either the principal or any agent or successor | 20 | | agent under the foregoing power of attorney, whether such | 21 | | relationship is by blood, marriage, or adoption; or (d) an | 22 | | agent or successor agent under the foregoing power of attorney.
| 23 | | .......................
| 24 | | (Witness Signature)
| 25 | | .......................
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| 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 | 7 | | successor agents to provide specimen signatures below. If you | 8 | | include specimen signatures in this power of attorney, you must | 9 | | complete the certification opposite the signatures of the | 10 | | agents.)
| 11 | | Specimen signatures of I certify that the signatures of my
| 12 | | agent (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 | 20 | | preparing this form or who assisted the principal in completing | 21 | | this form is optional.) | 22 | | .........................
| 23 | | (name of preparer)
| 24 | | .........................
| 25 | | .........................
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| 1 | | (address)
| 2 | | .........................
| 3 | | (phone)
| 4 | | (c) The statutory short form power of attorney for health | 5 | | care (the
"statutory health care power") authorizes the agent | 6 | | to make any and all
health care decisions on behalf of the | 7 | | principal which the principal could
make if present and under | 8 | | no disability, subject to any limitations on the
granted powers | 9 | | that appear on the face of the form, to be exercised in such
| 10 | | manner as the agent deems consistent with the intent and | 11 | | desires of the
principal. The agent will be under no duty to | 12 | | exercise granted powers or
to assume control of or | 13 | | responsibility for the principal's health care;
but when | 14 | | granted powers are exercised, the agent will be required to use
| 15 | | due care to act for the benefit of the principal in accordance | 16 | | with the
terms of the statutory health care power and will be | 17 | | liable
for negligent exercise. The agent may act in person or | 18 | | through others
reasonably employed by the agent for that | 19 | | purpose
but may not delegate authority to make health care | 20 | | decisions. The agent
may sign and deliver all instruments, | 21 | | negotiate and enter into all
agreements and do all other acts | 22 | | reasonably necessary to implement the
exercise of the powers | 23 | | granted to the agent. Without limiting the
generality of the | 24 | | foregoing, the statutory health care power shall include
the | 25 | | following powers, subject to any limitations appearing on the | 26 | | face of the form:
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| 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.
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| 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 | | (755 ILCS 45/4-12) (from Ch. 110 1/2, par. 804-12)
| 21 | | Sec. 4-12. Saving clause. This Act does not in any way
| 22 | | invalidate any health care agency executed or any act of any
| 23 | | agent done, or affect any claim, right or
remedy that accrued, | 24 | | prior to September 22, 1987.
| 25 | | This amendatory Act of the 96th General Assembly does not |
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| 1 | | in any way invalidate any health care agency executed or any | 2 | | act of any agent done, or affect any claim, right, or remedy | 3 | | that accrued, prior to the effective date of this amendatory | 4 | | Act of the 96th General Assembly. | 5 | | This amendatory Act of the 98th General Assembly does not | 6 | | in any way invalidate any health care agency executed or any | 7 | | act of any agent done, or affect any claim, right, or remedy | 8 | | that accrued, prior to the effective date of this amendatory | 9 | | Act of the 98th General Assembly. | 10 | | (Source: P.A. 96-1195, eff. 7-1-11 .)
| 11 | | Section 99. Effective date. This Act takes effect January | 12 | | 1, 2015.
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