Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care printable pdf download

ILLINOIS STATUTORY SHORT FORM

POWER OF ATTORNEY FOR

HEALTH CARE

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 also must 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 also may 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)

A5625

Rev. 09/01/2011

800 E. Carpenter Street · Springfield, Illinois 62769

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Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care