Form 5625 - Illinois Statutory Short Form Power Of Attorney For Health Care
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2ILLINOIS 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 A POWER IS EXERCISED, YOUR
AGENT WILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM. A COURT CAN TAKE AWAY THE
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 organ(s): __________________________________________________________________________________
(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 limitations (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.):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
(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):
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 a coma which my attending
physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered
irreversible coma, I want life-sustaining treatment to be withheld or discontinued.
Initialed _______________________________
#5625 (R 01/00)
(continued on reverse side)
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