$17.95

Add to cart

Illinois and to direct the disposition of the principal's remains. 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 Uniform Anatomical Gift Act, as now or hereafter amended; logist, therapist, hospital, nursing home or other health care provider. (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 xercise 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, psychoincipal'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 eal. Illinois Statutory Short Form Power of Attorney for Health Care Page 7 (4) At the principal's expense and subject to reasonable rules of the health care provider to prevent disruption of the prtatutory 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 princip 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 schild 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 ofonal 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 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 persl 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 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 mentaed 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) 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 granttory 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 makeity 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 statue 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 responsibil 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 biable and guilty of a Class A misdemeanor. (Sec 4-10(b).) The statutory short form power of attorney for health care (the "statutory health care power") authorizes the agent to make any and all healthntary manslaughter. (c) Any person who requires or prevents execution of a health care agency as a condition of insuring or providing any type of health care services to the patient shall be civilly lying procedures to be withheld or withdrawn Illinois Statutory Short Form Power of Attorney for Health Care Page 6 and death to the patient to be hastened shall be subject to prosecution for involuause a withholding or withdrawal of life-sustaining or death-delaying procedures contrary to the intent of the principal and thereby, because of such act, directly causes life-sustaining or death-delar revocation. (b) A person who falsifies or forges a health care agency or willfully conceals or withholds personal knowledge of an amendment or revocation of a health care agency with the intent to co, without the principal's consent, willfully conceals, cancels or alters a health care agency or any amendment or revocation of the agency or who falsifies or forges a health care agency, amendment ohe following sanctions in relation to health care agencies, in addition to all other sanctions applicable under any other law or rule of professional conduct: (a) Any person shall be civilly liable whevocation or amendment is communicated or delivered shall make all reasonable efforts to inform the agent of that fact as promptly as possible. (Sec. 4-9.) Penalties. All persons shall be subject to tth care agency may be amended at any time by a written amendment signed and dated by the principal or person acting at the direction of the principal. (c) Any person, other than the agent, to whom a rher expression of the intent to revoke the agency in the presence of a witness 18 years of age or older who signs and dates a writing confirming that such expression of intent was made. (b) Every healed in a manner indicating intention to revoke; 2. By a written revocation of the agency signed and dated by the principal or person acting at the direction of the principal; or 3. By an oral or any otoked by the principal at any time, without regard to the principal's mental or physical condition, by any of the following methods: 1. By being obliterated, burnt, torn or otherwise destroyed or defac law to administer health care in the ordinary course of business or the practice of a profession. (Sec. 4-6.) Revocation and amendment of health care agencies. (a) Every health care agency may be revson 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 byCare Page 5 APPENDIX A (Sec. 4-5.) Limitations on health care agencies. Neither the attending physician nor any other health care provider may act as agent under a health care agency; however, a per___________________________ (Principal) _________________________________ (Successor agent) _________________________________ (Principal) Illinois Statutory Short Form Power of Attorney for Health _____________ (Agent) I certify that the signature of my agent (and successors) are correct. _________________________________ (Principal) _________________________________ (Successor agent) ______u include specimen signatures in this power of attorney, you must complete the certification opposite the signatures of the agents.) Specimen signatures of agent (and successors) _________________________________________________ Residing at ____________________________ (witness) (You may, but are not required to, request your agent and successor agents to provide specimen signatures below. If yo___________________________ (principal) The principal has had an opportunity to read the above form and has signed the form or acknowledged his or her signature or mark on the form in my presence. __ of this form and understand the full import of this grant of powers to my agent. Illinois Statutory Short Form Power of Attorney for Health Care Page 4 Signed: ____________________________________ 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. The court will appoint your agent if the court finds that such appointment will serve your best interests and welfare. Strike out paragraph 6 if you do not want your agent to act as guardian.) 6. Ifian. (If you wish to name your agent as guardian of your person, in the event a court decides that one should be appointed, you may, but are not required to, do so by retaining the following paragraphle 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 physic___________________________________ ________________________________________________________________________ For purposes of this paragraph 5, a person shall be considered to be incompetent if and whiing (each to act alone and successively, in the order named) as successors to such agent: ________________________________________________________________________ _____________________________________d addresses of such successors in the following paragraph.) 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 follow (Insert a future date or event, such as court determination of your disability, when you want this power to terminate prior to your death.) (If you wish to name successor agents, insert the names any, when you want this power to first take effect) 4. ( ) This power of attorney shall terminate on ______________________________ _____________________________________________________________________ve ___________________________ ______________________________________________________________________ (insert a future date or event during your lifetime, such as court determination of your disabilitf remains is authorized, unless a limitation on the beginning date or duration is made by initialing and completing either or both of the following:) 3. ( ) This power of attorney shall become effectition, the authority granted in this power of attorney will become effective at the time this power is signed and will continue until your death, and beyond if anatomical gift, autopsy or disposition o 3 (This power of attorney may be amended or revoked by you in the manner provided in section 4-6 of the Illinois "powers of attorney for health care law" (see Appendix A). Absent amendment or revocat possible without regard to my condition, the chances I have for recovery or the cost of the procedures. Initialed _____________ Illinois Statutory Short Form Power of Attorney for Health Care Page reference. If and when I have suffered irreversible coma, I want life-sustaining treatment to be withheld or discontinued. Initialed _____________ I want my life to be prolonged to the greatest extenant 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 ofe 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 wo 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, thlife-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 d____________ (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 tion, psychosurgery, voluntary admission to a mental institution, etc.): _____________________________________________________________________ _________________________________________________________s 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, amputau 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 instructione 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 yond 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 thake 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 aStatutory Short Form Power of Attorney for Health Care Page 2 (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 m following (initial one): ______ Any organ: ______ Specific organs: __________________________________________________ ______________________________________________________________________ Illinois 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 thewithdraw 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 contentsr 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 ame and address of principal) hereby appoint: _______________________________________________________________________ (insert name and address of agent) as my attorney-in-fact (my "agent") to act fold ask a lawyer to explain it to you.) POWER OF ATTORNEY made this __________ day of___________________(month, year). 1. I, __________________________________________________________________ (insert nw" 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 shour 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 Lail 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 youerly. 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, untnd 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 proptal, 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 aions 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 hospiIllinois 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 decis Illinois