Illinois Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of Illinois. It allows you to designate someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- Phone Number: ___________________
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions, as determined by my attending physician.
Agent's Authority:
I grant my agent the authority to make all medical decisions on my behalf, including but not limited to:
- Choosing healthcare providers
- Consenting to or refusing medical treatment
- Accessing my medical records
- Making decisions regarding life-sustaining treatment
Limitations on Agent’s Authority:
My agent shall not have the authority to:
- Make decisions regarding my mental health treatment unless specified
- Make decisions that are contrary to my expressed wishes
Signature:
By signing below, I affirm that I am of sound mind and that I understand the nature of this document.
______________________________
Signature of Principal
Date: ________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to me or my agent.
Witness 1: ______________________
Signature: ______________________
Date: __________________________
Witness 2: ______________________
Signature: ______________________
Date: __________________________