Power Of Attorney For Health Care - Sage Medical Group printable pdf download

Illinois Statutory Short Form

Power of Attorney for Health Care

(NOTICE: the purpose of this power of attorney is to give the person you designate (your “agent”) broad powers

to make health care decisions for you, including power to require, consent to or withdraw any type of personal

care or medical treatment for any physical or mental condition and to admit you to or discharge you from any

hospital, home or other institution. This form does not impose a duty on your agent to exercise granted powers;

but when powers are exercised, your agent will have to use due care to act for your benefit and in accordance with

this form and keep a record of receipts, disbursements and significant actions taken as agent. A court can take

away powers of your agent if it finds the agent is not acting properly. You may name successor agents under this

form but not co-agents, and no health care provider may be named. Unless you expressly limit the duration of this

power in the manner provided below, until you revoke this power or a court acting on your behalf terminates it,

your agent may exercise the powers given here throughout your lifetime, even after you become disabled. 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, 4-9 and 4-10(b) of the Illinois “Powers of Attorney for Health Care Law”

of which this form is a part. That law expressly permits the use of any different form of power of attorney you may

desire. If there is anything about this form that you do not understand, you should ask a lawyer to explain it to you.)

POWER OF ATTORNEY made this __________ day of_______________________________________(month, year).

1. I, ______________________________________________________________________________________________

(insert name and address of principal)

hereby appoint: _____________________________________________________________________________________

(insert name and address of agent)

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. My agent shall have the same

access to my medical records that I have, including the right to disclose the contents to others. My agent shall also have

full power to authorize an autopsy and direct the disposition of my remains. Effective upon my death, my agent

has the full power to make an anatomical gift of the following (initial one):

Any organ:

Specific organs:

(The above grant of power is intended to be as broad as possible so that your agent will have 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 limita-

tions (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.):

_________________________________________________________________________________________________

(continued)

Power Of Attorney For Health Care - Sage Medical Group