Public Act 098-1113
 
SB3228 EnrolledLRB098 15174 HEP 55298 b


  
    AN ACT concerning civil law.
  
 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:
  
 
 
    Section 5. The Illinois Power of Attorney Act is amended  by 
changing Sections 4-4, 4-5, 4-5.1, 4-10, and 4-12 as follows:
 


    (755 ILCS 45/4-4)  (from Ch. 110 1/2, par. 804-4)




    Sec. 4-4. Definitions. As used in this Article:

    (a) "Attending physician" means the physician who has 
primary
responsibility at the time of reference for the 
treatment and care of the patient.

    (b) "Health care" means any care, treatment, service or 
procedure to
maintain, diagnose, treat or provide for the 
patient's physical or mental
health or personal care.

    (c) "Health care agency" means an agency governing any type 
of health
care, anatomical gift, autopsy or disposition of 
remains for and on behalf
of a patient and refers to the power 
of attorney or other written
instrument defining the agency or 
the agency, itself, as appropriate to the context.

    (d) "Health care provider", "health care professional", or 
"provider" means the attending physician
and any other person 
administering health care to the patient at the time
of 
reference who is licensed, certified, or otherwise authorized 
or
permitted by law to administer health care in the ordinary 
course of
business or the practice of a profession, including 
any person employed by
or acting for any such authorized 
person.

    (e) "Patient" means the principal or, if the agency governs 
health care
for a minor child of the principal, then the child.

    (e-5) "Health care agent" means an individual at least 18 
years old designated by the principal to make health care 
decisions of any type, including, but not limited to, 
anatomical gift, autopsy, or disposition of remains for and on 
behalf of the individual.  A health care agent is a personal 
representative under state and federal law. The health care 
agent has the authority of a personal representative under both 
state and federal law unless restricted specifically by the 
health care agency. 
    (f) (Blank).   "Incurable or irreversible condition" means 
an illness or injury (i) for which there is no reasonable 
prospect of cure or recovery, (ii) that ultimately will cause 
the patient's death even if life-sustaining treatment is 
initiated or continued, (iii) that imposes severe pain or 
otherwise imposes an inhumane burden on the patient, or (iv) 
for which initiating or continuing life-sustaining treatment, 
in light of the patient's medical condition, provides only 
minimal medical benefit.
    (g)      (Blank). "Permanent unconsciousness" means a condition 
that, to a high degree of medical certainty, (i) will last 
permanently, without improvement, (ii) in which thought, 
sensation, purposeful action, social interaction, and 
awareness of self and environment are absent, and (iii) for 
which initiating or continuing life-sustaining treatment, in 
light of the patient's medical condition, provides only minimal 
medical benefit. For the purposes of this definition, "medical 
benefit" means a chance to cure or reverse a condition.
    (h) (Blank).           "Terminal condition" means an illness or 
injury for which there is no reasonable prospect of cure or 
recovery, death is imminent, and the application of 
life-sustaining treatment would only prolong the dying 
process. 
(Source: P.A. 96-1195, eff. 7-1-11.)

 



    (755 ILCS 45/4-5)  (from Ch. 110 1/2, par. 804-5)



    Sec. 4-5. Limitations on health care agencies. Neither the 
attending
physician nor any other health care provider or 
health care professional may act as agent under a
health care 
agency; however, a person who is not administering health
care 
to the patient may act as health care agent for the patient 
even
though the person is a physician or otherwise licensed, 
certified,
authorized, or permitted by law to administer health 
care in the ordinary
course of business or the practice of a 
profession.

(Source: P.A. 86-736.)

 
    (755 ILCS 45/4-5.1)
    Sec. 4-5.1. Limitations on who may witness health care 
agencies.
    (a) Every health care agency shall bear the signature of a 
witness to the signing of the agency.  No witness may be under 
18 years of age. None of the following licensed professionals 
providing services to the principal may serve as a witness to 
the signing of a health care agency:
        (1) the attending physician, advanced practice nurse, 
    physician assistant, dentist, podiatric physician, 
    optometrist, or mental health service provider of the 
    principal, or a relative of the physician, advanced 
    practice nurse, physician assistant, dentist, podiatric 
    physician, optometrist, or mental health service provider;
        (2) an owner, operator, or relative of an owner or 
    operator of a health care facility in which the principal 
    is a patient or resident;
        (3) a parent, sibling, or descendant, or the spouse of 
    a parent, sibling, or descendant, of either the principal 
    or any agent or successor agent, regardless of whether the 
    relationship is by blood, marriage, or adoption;
        (4) an agent or successor agent for health care. 
    (b) The prohibition on the operator of a health care 
facility from serving as a witness shall extend to directors 
and executive officers of an operator that is a corporate 
entity but not other employees of the operator such as, but not 
limited to, non-owner chaplains or social workers, nurses, and 
other employees. 

(Source: P.A. 96-1195, eff. 7-1-11.)
 


    (755 ILCS 45/4-10)  (from Ch. 110 1/2, par. 804-10)



    Sec. 4-10. Statutory short form power of attorney for 
health care. 

    (a) The form prescribed in this Section (sometimes also 
referred to in this Act as the
"statutory health care power") 
may be used to grant an agent powers with
respect to the 
principal's own health care; but the statutory health care

power is not intended to be exclusive nor to cover delegation 
of a parent's
power to control the health care of a minor 
child, and no provision of this
Article shall be construed to 
invalidate or bar use by the principal of any
other or

different form of power of attorney for health care.  
Nonstatutory health
care powers must be
executed by the 
principal, designate the agent and the agent's powers, and

comply with the limitations in Section 4-5 of this Article, but 
they need not be witnessed or
conform in any other respect to 
the statutory health care power.
    No specific format is required for the statutory health 
care power of attorney other than the notice must precede the 
form. When a
power of attorney in substantially the
 form 
prescribed in this Section is used, including the "Notice to 
the Individual Signing the Illinois Statutory Short Form Power 
of Attorney for Health Care" (or "Notice" paragraphs) at the 
beginning of the form on a separate sheet in 14-point type, it 
shall have the meaning and effect prescribed in this
Act. A 
power of attorney for health care shall be deemed to be in 
substantially the same format as the statutory form if the 
explanatory language throughout the form (the language 
following the designation "NOTE:") is distinguished in some way 
from the legal paragraphs in the form, such as the use of 
boldface or other difference in typeface and font or point 
size, even if the "Notice" paragraphs at the beginning are not 
on a separate sheet of paper or are not in 14-point type, or if 
the principal's initials do not appear in the acknowledgement 
at the end of the "Notice" paragraphs.  The statutory health 
care power may be included in or
combined with any
other form 
of power of attorney governing property or other matters.

    (b) The Illinois Statutory Short Form Power of Attorney for 
Health Care shall be substantially as follows: 
 
NOTICE TO THE INDIVIDUAL SIGNING  
   
THE POWER OF ATTORNEY FOR HEALTH CARE  
    No one can predict when a serious illness or accident might 
occur. When it does, you may need someone else to speak or make 
health care decisions for you.  If you plan now, you can 
increase the chances that the medical treatment you get will be 
the treatment you want.
    In Illinois, you can choose someone to be your "health care 
agent".  Your agent is the person you trust to make health care 
decisions for you if you are unable or do not want to make them 
yourself. These decisions should be based on your personal 
values and wishes.
    It is important to put your choice of agent in writing. The 
written form is often called an "advance directive". You may 
use this form or another form, as long as it meets the legal 
requirements of Illinois. There are many written and on-line 
resources to guide you and your loved ones in having a 
conversation about these issues.  You may find it helpful to 
look at these resources while thinking about and discussing 
your advance directive. 
 
WHAT ARE THE THINGS I WANT MY  
  
HEALTH CARE AGENT TO KNOW?  
    The selection of your agent should be considered carefully, 
as your agent will have the ultimate decision making authority 
once this document goes into effect, in most instances after 
you are no longer able to make your own decisions.  While the 
goal is for your agent to make decisions in keeping with your 
preferences and in the majority of circumstances that is what 
happens, please know that the law does allow your agent to make 
decisions to direct or refuse health care interventions or 
withdraw treatment.  Your agent will need to think about 
conversations you have had, your personality, and how you 
handled important health care issues in the past.  Therefore, it 
is important to talk with your agent and your family about such 
things as:
        (i) What is most important to you in your life?
        (ii) How important is it to you to avoid pain and 
    suffering?
        (iii) If you had to choose, is it more important to you 
    to live as long as possible, or to avoid prolonged 
    suffering or disability?
        (iv) Would you rather be at home or in a hospital for 
    the last days or weeks of your life?
        (v) Do you have religious, spiritual, or cultural 
    beliefs that you want your agent and others to consider?
        (vi) Do you wish to make a significant contribution to 
    medical science after your death through organ or whole 
    body donation?
        (vii) Do you have an existing advanced directive, such 
    as a living will, that contains your specific wishes about 
    health care that is only delaying your death?  If you have 
    another advance directive, make sure to discuss with your 
    agent the directive and the treatment decisions contained 
    within that outline your preferences.  Make sure that your 
    agent agrees to honor the wishes expressed in your advance 
    directive. 
 
WHAT KIND OF DECISIONS CAN MY AGENT MAKE?  
    If there is ever a period of time when your physician 
determines that you cannot make your own health care decisions, 
or if you do not want to make your own decisions, some of the 
decisions your agent could make are to:
        (i) talk with physicians and other health care 
    providers about your condition.
        (ii) see medical records and approve who else can see 
    them.
        (iii) give permission for medical tests, medicines, 
    surgery, or other treatments.
        (iv) choose where you receive care and which physicians 
    and others provide it.
        (v) decide to accept, withdraw, or decline treatments 
    designed to keep you alive if you are near death or not 
    likely to recover. You may choose to include guidelines 
    and/or restrictions to your agent's authority.
        (vi) agree or decline to donate your organs or your 
    whole body if you have not already made this decision 
    yourself.  This could include donation for transplant, 
    research, and/or education.  You should let your agent know 
    whether you are registered as a donor in the First Person 
    Consent registry maintained by the Illinois Secretary of 
    State or whether you have agreed to donate your whole body 
    for medical research and/or education.
        (vii) decide what to do with your remains after you 
    have died, if you have not already made plans.
        (viii) talk with your other loved ones to help come to 
    a decision (but your designated agent will have the final 
    say over your other loved ones).
    Your agent is not automatically responsible for your health 
care expenses. 
 
WHOM SHOULD I CHOOSE TO BE MY HEALTH CARE AGENT?  
    You can pick a family member, but you do not have to. Your 
agent will have the responsibility to make medical treatment 
decisions, even if other people close to you might urge a 
different decision.  The selection of your agent should be done 
carefully, as he or she will have ultimate decision-making 
authority for your treatment decisions once you are no longer 
able to voice your preferences.  Choose a family member, friend, 
or other person who: 
        (i) is at least 18 years old;
        (ii) knows you well;
        (iii) you trust to do what is best for you and is 
    willing to carry out your wishes, even if he or she may not 
    agree with your wishes;
        (iv) would be comfortable talking with and questioning 
    your physicians and other health care providers;
        (v) would not be too upset to carry out your wishes if 
    you became very sick; and
        (vi) can be there for you when you need it and is 
    willing to accept this important role. 
 
WHAT IF MY AGENT IS NOT AVAILABLE OR IS  
  
UNWILLING TO MAKE DECISIONS FOR ME?  
    If the person who is your first choice is unable to carry 
out this role, then the second agent you chose will make the 
decisions; if your second agent is not available, then the 
third agent you chose will make the decisions.  The second and 
third agents are called your successor agents and they function 
as back-up agents to your first choice agent and may act only 
one at a time and in the order you list them. 
 
WHAT WILL HAPPEN IF I DO NOT  
  
CHOOSE A HEALTH CARE AGENT?  
    If you become unable to make your own health care decisions 
and have not named an agent in writing, your physician and 
other health care providers will ask a family member, friend, 
or guardian to make decisions for you. In Illinois, a law 
directs which of these individuals will be consulted.  In that 
law, each of these individuals is called a "surrogate". 
    There are reasons why you may want to name an agent rather 
than rely on a surrogate:
        (i) The person or people listed by this law may not be 
    who you would want to make decisions for you.
        (ii) Some family members or friends might not be able 
    or willing to make decisions as you would want them to.
        (iii) Family members and friends may disagree with one 
    another about the best decisions.
        (iv) Under some circumstances, a surrogate may not be 
    able to make the same kinds of decisions that an agent can 
    make.
 
WHAT IF THERE IS NO ONE AVAILABLE  
  
WHOM I TRUST TO BE MY AGENT?  
    In this situation, it is especially important to talk to 
your physician and other health care providers and create 
written guidance about what you want or do not want, in case 
you are ever critically ill and cannot express your own wishes.  
You can complete a living will.  You can also write your wishes 
down and/or discuss them with your physician or other health 
care provider and ask him or her to write it down in your 
chart.  You might also want to use written or on-line resources 
to guide you through this process. 
 
WHAT DO I DO WITH THIS FORM ONCE I COMPLETE IT?  
    Follow these instructions after you have completed the 
form: 
        (i) Sign the form in front of a witness.  See the form 
    for a list of who can and cannot witness it.
        (ii) Ask the witness to sign it, too.
        (iii) There is no need to have the form notarized.
        (iv) Give a copy to your agent and to each of your 
    successor agents.
        (v) Give another copy to your physician.
        (vi) Take a copy with you when you go to the hospital.
        (vii) Show it to your family and friends and others who 
    care for you. 
 
WHAT IF I CHANGE MY MIND?  
    You may change your mind at any time. If you do, tell 
someone who is at least 18 years old that you have changed your 
mind, and/or destroy your document and any copies. If you wish, 
fill out a new form and make sure everyone you gave the old 
form to has a copy of the new one, including, but not limited 
to, your agents and your physicians. 
 
WHAT IF I DO NOT WANT TO USE THIS FORM?  
    In the event you do not want to use the Illinois statutory 
form provided here, any document you complete must be executed 
by you, designate an agent who is over 18 years of age and not 
prohibited from serving as your agent, and state the agent's 
powers, but it need not be witnessed or conform in any other 
respect to the statutory health care power. 
    If you have questions about the use of any form, you may 
want to consult your physician, other health care provider, 
and/or an attorney. 
 
MY POWER OF ATTORNEY FOR HEALTH CARE  

 
THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY 
FOR HEALTH CARE. (You must sign this form and a witness must 
also sign it before it is valid) 
 
My name (Print your full name):..............................
My address:..................................................
 
I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT 
(an agent is your  personal representative under state and 
federal law): 
(Agent name).................................................
(Agent address)..............................................
(Agent phone number).........................................
 
MY AGENT CAN MAKE HEALTH CARE DECISIONS FOR ME, INCLUDING:
        (i) Deciding to accept, withdraw or decline treatment 
    for any physical or mental condition of mine, including 
    life-and-death decisions.
        (ii) Agreeing to admit me to or discharge me from any 
    hospital, home, or other institution, including a mental 
    health facility.
        (iii) Having complete access to my medical and mental 
    health records, and sharing them with others as needed, 
    including after I die.
        (iv) Carrying out the plans I have already made, or, if 
    I have not done so, making decisions about my body or 
    remains, including organ, tissue or whole body donation, 
    autopsy, cremation, and burial.
    The above grant of power is intended to be as broad as 
possible so that my agent will have the authority to make any 
decision I could make to obtain or terminate any type of health 
care, including withdrawal of nutrition and hydration and other 
life-sustaining measures. 
 
I AUTHORIZE MY AGENT TO (please check any one box): 
    .... Make decisions for me only when I cannot make them for 
    myself. The physician(s) taking care of me will determine 
    when I lack this ability.
        (If no box is checked, then the box above shall be 
    implemented.)
OR 
    .... Make decisions for me starting now and continuing 
    after I am no longer able to make them for myself.  While I 
    am still able to make my own decisions, I can still do so 
    if I want to. 
 
    The subject of life-sustaining treatment is of particular 
importance.  Life-sustaining treatments may include tube 
feedings or fluids through a tube, breathing machines, and CPR.  
In general, in making decisions concerning life-sustaining 
treatment, your agent is instructed to consider the relief of 
suffering, the quality as well as the possible extension of 
your life, and your previously expressed wishes.  Your agent 
will weigh the burdens versus benefits of proposed treatments 
in making decisions on your behalf.
    Additional statements concerning the withholding or 
removal of life-sustaining treatment are described below.  
These can serve as a guide for your agent when making decisions 
for you.  Ask your physician or health care provider if you have 
any questions about these statements. 
 
SELECT ONLY ONE STATEMENT BELOW THAT BEST EXPRESSES YOUR WISHES 
(optional): 
    .... The quality of my life is more important than the 
    length of my life. If I am unconscious and my attending 
    physician believes, in accordance with reasonable medical 
    standards, that I will not wake up or recover my ability to 
    think, communicate with my family and friends, and 
    experience my surroundings, I do not want treatments to 
    prolong my life or delay my death, but I do  want treatment 
    or care to make me comfortable and to relieve me of pain. 
    .... Staying alive is more important to me, no matter how 
    sick I am, how much I am suffering, the cost of the 
    procedures, or how unlikely my chances for recovery are. I 
    want my life to be prolonged to the greatest extent 
    possible in accordance with reasonable medical standards. 
 
SPECIFIC LIMITATIONS TO MY AGENT'S DECISION-MAKING AUTHORITY: 
    The above grant of power is intended to be as broad as 
possible so that your agent will have the authority to make any 
decision you could make to obtain or terminate any type of 
health care.  If you wish to limit the scope of your agent's 
powers or prescribe special rules or limit the power to 
authorize autopsy or dispose of remains, you may do so 
specifically in this form. 
.............................................................
.............................................................
 
My signature:................................................
Today's date:................................................
 
HAVE YOUR WITNESS AGREE TO WHAT IS WRITTEN BELOW, AND THEN 
COMPLETE THE SIGNATURE PORTION:
    I am at least 18 years old. (check one of the options 
below):
    .... I saw  the principal sign this document, or 
    .... the principal told me that the signature or mark on 
    the principal signature line is his or hers. 
    I am not the agent or successor agent(s) named in this 
document. I am not related to the principal, the agent, or the 
successor agent(s) by blood, marriage, or adoption. I am not 
the principal's physician, mental health service provider, or a 
relative of one of those individuals. I am not an owner or 
operator (or the relative of an owner or operator) of the 
health care facility where the principal is a patient or 
resident.
Witness printed name:........................................
Witness address:.............................................
Witness signature:...........................................
Today's date:................................................
 
SUCCESSOR HEALTH CARE AGENT(S) (optional):
    If the agent I selected is unable or does not want to make 
health care decisions for me, then I request the person(s) I 
name below to be my successor health care agent(s). Only one 
person at a time can serve as my agent (add another page if you 
want to add more successor agent names): 
.............................................................
(Successor agent #1 name, address and phone number) 
.............................................................
(Successor agent #2 name, address and phone number) 
 
"NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS   
  
STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE  

 
    PLEASE READ THIS NOTICE CAREFULLY.  The form that you will 
be signing is a legal document.  It is governed by the Illinois 
Power of Attorney Act.  If there is anything about this form 
that you do not understand, you should ask a lawyer to explain 
it to you.
    The purpose of this Power of Attorney is to give your 
designated "agent" broad powers to make health care decisions 
for you, including the power to require, consent to, or 
withdraw treatment for any physical or mental condition, and to 
admit you or discharge you from any hospital, home, or other 
institution. You may name successor agents under this form, but 
you may not name co-agents.
    This form does not impose a duty upon your agent to make 
such health care decisions, so it is important that you select 
an agent who will agree to do this for you and who will make 
those decisions as you would wish.  It is also important to 
select an agent whom you trust, since you are giving that agent 
control over your medical decision-making, including 
end-of-life decisions.  Any agent who does act for you has a 
duty to act in good faith for your benefit and to use due care, 
competence, and diligence.  He or she must also act in 
accordance with the law and with the statements in this form.  
Your agent must keep a record of all significant actions taken 
as your agent.
    Unless you specifically limit the period of time that this 
Power of Attorney will be in effect, your agent may exercise 
the powers given to him or her throughout your lifetime, even 
after you become disabled.  A court, however, can take away the 
powers of your agent if it finds that the agent is not acting 
properly.  You may also revoke this Power of Attorney if you 
wish.
    The Powers you give your agent, your right to revoke those 
powers, and the penalties for violating the law are explained 
more fully in Sections 4-5, 4-6, and 4-10(c)   of the Illinois 
Power of Attorney Act. This form is a part of that law.  The 
"NOTE" paragraphs throughout this form are instructions.
    You are not required to sign this Power of Attorney, but it 
will not take effect without your signature.  You should not 
sign it if you do not understand everything in it, and what 
your agent will be able to do if you do sign it.
 
    Please put your initials on the following line indicating 
that you have read this Notice: 
......................
 
(Principal's initials)"
 

 
"ILLINOIS STATUTORY SHORT FORM
  
POWER OF ATTORNEY FOR HEALTH CARE


 


    1. I, ..................................................,
              
(insert name and address of principal)
hereby revoke all prior 
powers of attorney for health care executed by me and appoint:

............................................................
          
(insert name and address of agent)

(NOTE: You may not name co-agents using this form.) 
as my attorney-in-fact (my "agent") to act for me and in my 
name (in any
way I could act in person) to make any and all 
decisions for me concerning
my personal care, medical 
treatment, hospitalization and health care and to
require, 
withhold or withdraw any type of medical treatment or 
procedure,
even though my death may ensue.
    A.  My agent shall have the same access to my
medical 
records that I have, including the right to disclose the 
contents
to others.  
    B.
Effective upon my death, my agent has the full power to 
make an anatomical
gift of the following: 
(NOTE: Initial one. In the event none of the options are 
initialed, then it shall be concluded that you do not wish to 
grant your agent any such authority.)


        .... Any organs, tissues, or eyes suitable for 
    transplantation or used for
research or education.


        .... Specific organs:................................

        .... I do not grant my agent authority to make any 
    anatomical gifts. 
    C. My agent shall also have full power to authorize an 
autopsy and direct the disposition of my remains. I intend for 
this power of attorney to be in substantial compliance with 
Section 10 of the Disposition of Remains Act. All decisions 
made by my agent with respect to the disposition of my remains, 
including cremation, shall be binding. I hereby direct any 
cemetery organization, business operating a crematory or 
columbarium or both, funeral director or embalmer, or funeral 
establishment who receives a copy of this document to act under 
it.
    D. I intend for the person named as my agent to be treated 
as I would be with respect to my rights regarding the use and 
disclosure of my individually identifiable health information 
or other medical records, including records or communications 
governed by the Mental Health and Developmental Disabilities 
Confidentiality Act.  This release authority applies to any 
information governed by the Health Insurance Portability and 
Accountability Act of 1996 ("HIPAA") and regulations 
thereunder. I intend for the person named as my agent to serve 
as my "personal representative" as that term is defined under 
HIPAA and regulations thereunder.
    (i) The person named as my agent shall have the power to 
authorize the release of information governed by HIPAA to third 
parties.
    (ii) I authorize any physician, health care professional, 
dentist, health plan, hospital, clinic, laboratory, pharmacy 
or other covered health care provider, any insurance company 
and the Medical Informational Bureau, Inc., or any other health 
care clearinghouse that has provided treatment or services to 
me, or that has paid for or is seeking payment for me for such 
services to give, disclose, and release to the person named as 
my agent, without restriction, all of my individually 
identifiable health information and medical records, regarding 
any past, present, or future medical or mental health 
condition, including all information relating to the diagnosis 
and treatment of HIV/AIDS, sexually transmitted diseases, drug 
or alcohol abuse, and mental illness (including records or 
communications governed by the Mental Health and Developmental 
Disabilities Confidentiality Act).
    (iii) The authority given to the person named as my agent 
shall supersede any prior agreement that I may have with my 
health care providers to restrict access to, or disclosure of, 
my individually identifiable health information.  The authority 
given to the person named as my agent has no expiration date 
and shall expire only in the event that I revoke the authority 
in writing and deliver it to my health care provider.   
(NOTE: The above grant of power is intended to be as broad as 
possible so that your agent will have the authority to make any 
decision you could make to obtain or terminate any type of 
health care, including withdrawal of food and water and other 
life-sustaining measures, if your agent believes such action 
would be consistent with your intent and desires.  If you wish 
to limit the scope of your agent's powers or prescribe special 
rules or limit the power to make an anatomical gift, authorize 
autopsy or dispose of remains, you may do so in the following 
paragraphs.) 

    2. The powers granted above shall not include the following 
powers or
shall be subject to the following rules or 
limitations:
(NOTE: Here  you may include
any specific limitations you deem 
appropriate, such as:  your own
definition of when 
life-sustaining measures should be withheld; a direction
to 
continue food and fluids or life-sustaining treatment in
all 
events; or instructions to refuse
any specific types of 
treatment that are inconsistent with your religious
beliefs or 
unacceptable to you for any other reason, such as blood

transfusion, electro-convulsive therapy, amputation, 
psychosurgery,
voluntary admission to a mental institution, 
etc.) 

.............................................................

.............................................................

.............................................................

.............................................................

.............................................................

(NOTE: The subject of life-sustaining treatment is of 
particular importance.  For your convenience in dealing with 
that subject, some general statements concerning the 
withholding or removal of life-sustaining treatment are set 
forth below.  If you agree with one of these statements, you may 
initial that statement; but do not initial more than one. These 
statements serve as guidance for your agent, who shall give 
careful consideration to the statement you initial when 
engaging in health care decision-making on your behalf.) 

    I do not want my life to be prolonged nor do I want 
life-sustaining
treatment to be provided or continued if my 
agent believes the burdens of
the treatment outweigh the 
expected benefits.  I want my agent to consider
the relief of 
suffering, the expense involved and the quality as well as
the 
possible extension of my life in making decisions concerning

life-sustaining treatment.

Initialed ...........................


    I want my life to be prolonged and I want life-sustaining 
treatment to be
provided or continued, unless I am, in the 
opinion of my attending physician, in accordance with 
reasonable medical
standards at the time of reference, in a 
state of "permanent unconsciousness" or suffer from an 
"incurable or irreversible condition" or "terminal condition", 
as those terms are defined in Section 4-4 of the Illinois Power 
of Attorney Act.  If and when I am in  any one of these states or 
conditions,  I want life-sustaining treatment to be withheld or

discontinued. 

Initialed ...........................


    I want my life to be prolonged to the greatest extent 
possible in accordance with reasonable medical standards 
without
regard to my condition, the chances I have for recovery 
or the cost of the
procedures.

Initialed ...........................


(NOTE: This power of attorney may be amended or revoked by you 
in the manner provided in Section 4-6 of the Illinois Power of 
Attorney Act.)

    3.   This power of attorney shall become effective on

.............................................................

.............................................................

(NOTE: Insert  a future date or event during your lifetime, such 
as a court
determination of your disability or a written 
determination by your physician that you are incapacitated, 
when you want this power to first take
effect.)

(NOTE: If you do not amend or revoke this power, or if you do 
not specify a specific ending date in paragraph 4, it will 
remain in effect until your death; except that your agent will 
still have the authority to donate your organs, authorize an 
autopsy, and dispose of your remains after your death, if you 
grant that authority to your agent.) 
    4.   This power of attorney shall terminate on
..........

.............................................................

(NOTE: Insert  a future date or event, such as a court 
determination that you are not under a legal disability or a 
written determination by your physician that you are not 
incapacitated, if  you want this power to terminate prior to 
your death.)

(NOTE: You cannot use this form to name co-agents. If you wish 
to name successor agents, insert the names and addresses of the 
successors in paragraph 5.) 

    5. If any agent named by me shall die, become incompetent, 
resign,
refuse to accept the office of agent or be unavailable, 
I name
the following (each to act alone
and successively, in 
the order named) as successors to such agent:

.............................................................

.............................................................

For purposes of this paragraph 5, a person shall be considered 
to be
incompetent if and while the person is a minor, or an 
adjudicated
incompetent or disabled person, or the person is 
unable to give prompt and
intelligent consideration to health 
care matters, as certified by a licensed physician.

(NOTE: If you wish to, you may name your agent as guardian of 
your person if a court decides that one should be appointed. To 
do this, retain paragraph 6, and the court will appoint your 
agent if the court finds that this appointment will serve your 
best interests and welfare.  Strike out paragraph 6 if you do 
not want your agent to act as guardian.)

    6. If a guardian of my person is to be appointed, I 
nominate the agent
acting under this power of attorney as such

guardian, to serve without bond or security.

    7. I am fully informed as to all the contents of this form 
and
understand the full import of this grant of powers to my 
agent.

Dated: .......... 
 
Signed ..............................


             
(principal's signature or mark)
  

 
    The principal has had an opportunity to review  the above 
form and has
signed the form or acknowledged his or her 
signature or mark on the form in my presence. The undersigned 
witness certifies that the witness is not: (a) the attending 
physician or mental health service provider or a relative of 
the physician or provider; (b) an owner, operator, or relative 
of an owner or operator of a health care facility in which the 
principal is a patient or resident; (c) a parent, sibling, 
descendant, or any spouse of such parent, sibling, or 
descendant of either the principal or any agent or successor 
agent under the foregoing power of attorney, whether such 
relationship is by blood, marriage, or adoption; or (d) an 
agent or successor agent under the foregoing power of attorney. 

   
.......................
(Witness Signature)
.......................
(Print Witness Name)
.......................
(Street Address)
.......................
(City, State, ZIP)


(NOTE: You may, but are not required to, request your agent and 
successor agents to provide specimen signatures below.  If you 
include specimen signatures in this power of attorney, you must 
complete the certification opposite the signatures of the 
agents.) 

Specimen signatures of    I certify that the signatures of my

agent (and successors).   agent (and successors) are correct.

.......................   ...................................

       (agent)                      (principal)

.......................   ...................................

   (successor agent)                (principal)

.......................   ...................................

   (successor agent)                (principal)"

 
    (NOTE: The name, address, and phone number of the person 
preparing this form or who assisted the principal in completing 
this form is optional.) 
.........................
 
(name of preparer)
 
.........................
 
.........................
 
(address)
 
.........................
 
(phone)
 
    (c)  The statutory short form power of attorney for health 
care (the
"statutory health care power") authorizes the agent 
to make any and all
health care decisions on behalf of the 
principal which the principal could
make if present and under 
no disability, subject to any limitations on the
granted powers 
that appear on the face of the form, to be exercised in such

manner as the agent deems consistent with the intent and 
desires of the
principal.  The agent will be under no duty to 
exercise granted powers or
to assume control of or 
responsibility for the  principal's health care;
but when 
granted powers are exercised, the agent will be required to use

due care to act for the benefit of the principal in accordance 
with the
terms of the statutory health care power and will be 
liable
for negligent exercise.   The agent may act in person or 
through others
reasonably employed by the agent for that 
purpose
but may not delegate authority to make health care 
decisions.  The agent
may sign and deliver all instruments, 
negotiate and enter into all
agreements and do all other acts 
reasonably necessary to implement the
exercise of the powers 
granted to the agent.  Without limiting the
generality of the 
foregoing, the statutory health care power shall include
the 
following powers, subject to any limitations appearing on the 
face of the form:

        (1) The agent is authorized to give consent to and 
    authorize or refuse,
or to withhold or withdraw consent to, 
    any and all types of medical care,
treatment or procedures 
    relating to the physical or mental health of the
principal, 
    including any medication program, surgical procedures,

    life-sustaining treatment or provision of food and fluids 
    for the principal.

        (2) The agent is authorized to admit the principal to 
    or discharge the
principal from any and all types of 
    hospitals, institutions, homes,
residential or nursing 
    facilities, treatment centers and other health care

    institutions providing personal care or treatment for any 
    type of physical
or mental condition.  The agent shall have 
    the same right to visit the
principal in the hospital or 
    other institution as is granted to a spouse or
adult child 
    of the principal, any rule of the institution to the 
    contrary
notwithstanding.

        (3) The agent is authorized to contract for any and all 
    types of health
care services and facilities in the name of 
    and on behalf of the principal
and to bind the principal to 
    pay for all such services and facilities,
and to have and 
    exercise those powers over the principal's property as are

    authorized under the statutory property power, to the 
    extent the agent
deems necessary to pay health care costs; 
    and
the agent shall not be personally liable for any 
    services or care contracted
for on behalf of the principal.

        (4) At the principal's expense and subject to 
    reasonable rules of the
health care provider to prevent 
    disruption of the principal's health care,
the agent shall 
    have the same right the principal has to examine and copy

    and consent to disclosure of all the principal's medical 
    records that the agent deems
relevant to the exercise of 
    the agent's powers, whether the records
relate to mental 
    health or any other medical condition and whether they are 
    in
the possession of or maintained by any physician, 
    psychiatrist,
psychologist, therapist, hospital, nursing 
    home or other health care
provider. The authority under 
    this paragraph (4) applies to any information governed by 
    the Health Insurance Portability and Accountability Act of 
    1996 ("HIPAA") and regulations thereunder. The agent 
    serves as the principal's personal representative, as that 
    term is defined under HIPAA and regulations thereunder.

        (5) The agent is authorized: to direct that an autopsy 
    be made pursuant
to Section 2 of "An Act in relation to 
    autopsy of dead bodies", approved
August 13, 1965, 
    including all amendments;
to make a disposition of any
part 
    or all of the principal's body pursuant to the Illinois 
    Anatomical Gift
Act, as now or hereafter amended; and to 
    direct the disposition of the
principal's remains.

(Source: P.A. 96-1195, eff. 7-1-11; 97-148, eff. 7-14-11.)

 


    (755 ILCS 45/4-12)  (from Ch. 110 1/2, par. 804-12)




    Sec. 4-12. Saving clause. This Act does not in any way

invalidate any health care agency executed or any act of any

agent done, or affect any claim, right or
remedy that accrued, 
prior to September 22, 1987.

    This amendatory Act of the 96th General Assembly does not 
in any way invalidate any health care agency executed or any 
act of any agent done, or affect any claim, right, or remedy 
that accrued, prior to the effective date of this amendatory 
Act of the 96th General Assembly.
    This amendatory Act of the 98th General Assembly does not 
in any way invalidate any health care agency executed or any 
act of any agent done, or affect any claim, right, or remedy 
that accrued, prior to the effective date of this amendatory 
Act of the 98th General Assembly. 
(Source: P.A. 96-1195, eff. 7-1-11.)

  
 
    Section 99. Effective date. This Act takes effect January 
1, 2015.