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Blank Illinois Short Power Form

The Illinois Short Power of Attorney for Health Care is a legal document that allows you to designate someone to make health care decisions on your behalf. This form grants your chosen agent broad authority to manage your medical care, including the ability to consent to or withdraw treatment. Understanding this form is crucial, as it empowers your agent to act in your best interest when you may not be able to do so yourself.

Outline

The Illinois Statutory Short Form Power of Attorney for Health Care is a crucial legal document that empowers an individual to designate someone else, known as an agent, to make health care decisions on their behalf. This form is governed by the Illinois Power of Attorney Act and is designed to ensure that your medical preferences are respected, especially in situations where you may be unable to communicate your wishes. By signing this document, you grant your agent broad authority to make decisions regarding your medical treatment, hospitalization, and even end-of-life care. Importantly, you can specify successor agents, but co-agents are not permitted. The form does not obligate your agent to act; therefore, selecting someone you trust is essential. Your agent will be responsible for keeping records of their decisions and must act in good faith, adhering to your expressed wishes. The power of attorney remains effective throughout your lifetime unless you decide to revoke it or a court determines otherwise. It is vital to read the notice carefully, understand its implications, and consult a lawyer if you have any questions before signing. This form also addresses issues such as anatomical gifts, autopsy authorization, and the handling of your medical records, ensuring comprehensive coverage of your health care preferences.

Sample - Illinois Short Power Form

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 beneit and to use due care, competence, and diligence. He or she must also act in accordance with the law and with the statements in this form. Your agent must keep a record of all signiicant actions taken as your agent.

Unless you speciically 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 inds that the agent is not acting properly. You may also 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)

A-1

ILLINOIS STATUTORY SHORT FORM

POWER OF ATTORNEY FOR HEALTH CARE

1.I, _______________________________________________________________________, (insert name and address of principal)

hereby revoke all prior powers of attorney for health care executed by me and appoint:

_____________________________________________________________________________

(insert name and address of agent)

(NOTE: You may not name co-agents using this form.)

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.

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

B.Effective upon my death, my agent has the full power to make an anatomical gift of the following:

(NOTE: Initial one. In the event none of the options are initialed, then it shall be concluded that you do not wish to grant your agent any such authority.)

______ Any organs, tissues, or eyes suitable for transplantation or used for research or education.

______ Speciic Organs:____________________________________________________

______ I do not grant my agent authority to make any anatomical gifts.

C.My agent shall also have full power to authorize an autopsy and direct the disposition of my remains. I intend for this power of attorney to be in substantial compliance with Section 10 of the Disposition of Remains Act. All decisions made by my agent with respect to the disposition of my remains, including cremation, shall be binding. I hereby direct any cemetery organization, business operating a crematory or columbarium or both, funeral director or embalmer, or funeral establishment who receives a copy of this document to act under it.

B-1

D.I intend for the person named as my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identiiable health information or other medical records, including records or communications governed by the Mental Health and Developmental Disabilities Conidentiality Act. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996

(“HIPAA”) and regulations thereunder. I intend for the person named as my agent to serve as my “personal representative” as that term is deined under HIPAA and regulations thereunder.

(i)The person named as my agent shall have the power to authorize the release of information governed by HIPAA to third parties.

(ii)I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider, any insurance company and the Medical Informational Bureau, Inc., or any other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment for me

for such services to give, disclose, and release to the person named as my agent, without restriction, all of my individually identiiable health information and medical records, regarding any past, present, or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted

diseases, drug or alcohol abuse, and mental illness (including records or communications governed by the Mental Health and Developmental Disabilities Conidentiality Act).

(iii)The authority given to the person named as my agent shall supersede any prior agreement

that I may have with my health care providers to restrict access to, or disclosure of, my individually identiiable health information. The authority given to the person named as my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider.

(NOTE: The above grant of power is intended to be as broad as possible so that your agent will have the 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.)

B-2

2.The powers granted above shall not include the following powers or shall be subject to the following rules or limitations:

(NOTE: Here you may include any speciic limitations you deem appropriate, such as: your own deinition of when life-sustaining measures should be withheld; a direction to continue food and luids or life-sustaining treatment in all events; or instructions to refuse any speciic 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.)

_____________________________________________________________________________

(NOTE: 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. These statements serve as

guidance for your agent, who shall give careful consideration to the statement you initial when engaging in health care decision-making on your behalf.)

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 beneits. 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 the opinion of my attending physician, in accordance with reasonable medical

standards at the time of reference, in a state of “permanent unconsciousness” or suffer from an “incurable or irreversible condition” or “terminal condition”, as those terms are deined in Section 4-4 of the Illinois Power of Attorney Act. If and when I am in any one of these states or

conditions, I want life-sustaining treatment to be withheld or discontinued.

Initialed __________

I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards without regard to my condition, the chances I have for recovery or the cost of the procedures.

Initialed __________

B-3

(NOTE: This power of attorney may be amended or revoked by you in the manner provided in Section 4-6 of the Illinois Power of Attorney Act. )

3.This power of attorney shall become effective on: _________________________________

_____________________________________________________________________________

(NOTE: In Line 3 above, insert a future date or event during your lifetime, such as a court

determination of your disability or a written determination by your physician that you are incapacitated, when you want this power to irst take effect.)

(NOTE: If you do not amend or revoke this power, or if you do not specify a speciic ending date

in paragraph 4, it will remain in effect until your death; except that your agent will still have the

authority to donate your organs, authorize an autopsy, and dispose of your remains after your death, if you grant that authority to your agent.)

4.This power of attorney shall terminate on: _______________________________________

_____________________________________________________________________________

(NOTE: In Line 4 above, insert a future date or event, such as a court determination that you

are not under a legal disability or a written determination by your physician that you are not incapacitated, if you want this power to terminate prior to your death.)

(NOTE: You cannot use this form to name co-agents. If you wish to name successor agents, insert the names and addresses of the successors in paragraph 5.)

5.If any agent named by me shall die, become incompetent, resign, refuse to accept the ofice of agent or be unavailable, I name the following (each to act alone and successively, in the order named) as successors to such agent:

_____________________________________________________________________________

(insert name and address of successor agent)

_____________________________________________________________________________

(insert name and address of successor agent)

For purposes of this paragraph 5, a person shall be considered to be incompetent if and while 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 certiied by a licensed physician.

(NOTE: If you wish to, you may name your agent as guardian of your person if a court decides

that one should be appointed. To do this, retain paragraph 6, and the court will appoint your agent if the court inds that this appointment will serve your best interests and welfare. Strike out paragraph 6 if you do not want your agent to act as guardian.)

6.If 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 of this form and understand the full import of this grant of powers to my agent.

Dated: ___________________	Signed: __________________________________________
	(principal’s signature or mark)
	B-4

The principal has had an opportunity to review the above form and has signed the form or

acknowledged his or her signature or mark on the form in my presence. The undersigned witness certiies that the witness is not: (a) the attending physician or mental health service provider or a

relative of the physician or provider; (b) an owner, operator, or relative of an owner or operator of a health care facility in which the principal is a patient or resident; (c) a parent, sibling or descendant, or any spouse of such parent, sibling, or descendant of either the principal or any agent or successor agent under the foregoing power of attorney, whether such relationship is by blood, marriage, or adoption; or

(d) an agent or successor agent under the foregoing power of attorney.

______________________________________

(Witness Signature)

______________________________________

(Print Witness Name)

______________________________________

(Street Address)

______________________________________

(City, State, ZIP)

(NOTE: You may, but are not required to, request your agent and successor agents to provide

specimen signatures below. If you include specimen signatures in this power of attorney, you must complete the certiication opposite the signatures of the agents.)

Specimen signatures of agent (and successors).	I certify that the signatures of my agent (and
	successors) are correct.
________________________________________	________________________________________
(agent)	(principal)
________________________________________	________________________________________
(successor agent)	(principal)
________________________________________	________________________________________
(successor agent)	(principal)

(NOTE: The name, address, and phone number of the person preparing this form or who assisted the principal in completing this form is optional.)

___________________________________

(name of preparer)

___________________________________

(address)

___________________________________

(address)

___________________________________

(phone)

B-5

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Form Information

Fact Name	Fact Description
Governing Law	This form is governed by the Illinois Power of Attorney Act.
Purpose	The purpose is to appoint an agent to make health care decisions on your behalf.
Agent Authority	Your agent can consent to or withdraw treatment and manage hospital admissions.
Successor Agents	You may name successor agents, but co-agents are not allowed.
Agent's Duty	Your agent must act in good faith and in your best interest.
Record Keeping	Your agent is required to keep a record of significant actions taken on your behalf.
Revocation	You can revoke this power of attorney at any time if you choose.
Life-Sustaining Treatment	You can specify your preferences regarding life-sustaining treatment in the form.
Effective Date	The power of attorney can become effective upon a specified future event or date.

Detailed Guide for Filling Out Illinois Short Power

Filling out the Illinois Short Power of Attorney for Health Care form is an important step in ensuring that your health care decisions are made according to your wishes. This document allows you to appoint an agent who will make medical decisions on your behalf if you are unable to do so. It is essential to carefully consider your choices and the implications of this form before proceeding.

Read the Notice: Begin by carefully reading the notice at the top of the form. It contains important information about the powers you are granting to your agent.
Initial the Notice: After reading the notice, put your initials in the designated space to indicate that you understand the information provided.
Fill in Your Information: In the first section, write your full name and address as the principal.
Appoint Your Agent: Enter the name and address of the person you are designating as your agent.
Grant Powers: Review and understand the powers you are granting to your agent regarding your health care decisions.
Specify Anatomical Gifts: Indicate your wishes regarding organ donation by checking the appropriate box and providing details if necessary.
Autopsy and Disposition of Remains: Confirm that you want your agent to have the authority to authorize an autopsy and direct the disposition of your remains.
HIPAA Release: Acknowledge that your agent will have access to your medical records and can authorize their release to others.
Limitations on Powers: If you wish to impose any limitations on the powers granted to your agent, write them in the space provided.
Life-Sustaining Treatment Preferences: Review the statements regarding life-sustaining treatment and initial the one that reflects your wishes.
Effective Date: Specify when this power of attorney will become effective, whether it's a specific date or an event.
Termination Date: Indicate when you want this power of attorney to terminate, if applicable.
Name Successor Agents: If desired, name any successor agents who will take over if your primary agent is unable to serve.
Nominating a Guardian: If you want your agent to be appointed as your guardian in the event of a court decision, indicate this by keeping the relevant paragraph.
Sign and Date: Finally, sign and date the form. Your signature confirms that you understand and agree to the contents of the document.

Once you have completed the form, it is advisable to keep it in a safe place and share copies with your agent and any relevant family members or health care providers. This ensures that your wishes are known and can be honored when needed.

Obtain Answers on Illinois Short Power

What is the Illinois Short Power of Attorney for Health Care?
The Illinois Short Power of Attorney for Health Care is a legal document that allows you to appoint an agent to make health care decisions on your behalf. This includes decisions about medical treatment, hospitalization, and end-of-life care. It is governed by the Illinois Power of Attorney Act.
Who can I appoint as my agent?
You can appoint any adult you trust as your agent. This person will have the authority to make health care decisions for you when you are unable to do so yourself. However, you cannot name co-agents; you can only appoint one agent at a time.
Can I limit the powers granted to my agent?
Yes, you can specify limitations on the powers granted to your agent. For example, you may choose to restrict certain types of medical treatments or specify your wishes regarding life-sustaining measures. It's important to clearly outline any limitations in the document.
What happens if I become incapacitated?
If you become incapacitated, your agent can begin making health care decisions on your behalf, as long as the power of attorney is effective at that time. You can specify when the power of attorney becomes effective, such as upon a physician's determination of your incapacity.
Can I revoke the Power of Attorney?
Yes, you have the right to revoke the Power of Attorney at any time. To do this, you must provide a written notice of revocation to your agent and any health care providers involved in your care.
What responsibilities does my agent have?
Your agent has a duty to act in your best interest and to make decisions that align with your wishes. They must keep a record of significant actions taken on your behalf and act in good faith.
What if my agent cannot serve?
If your appointed agent is unable to serve due to death, incompetence, or refusal, you can name successor agents in the document. These successors will step in to make decisions for you in the order you specify.
What is the role of the “Notice” section?
The “Notice” section is meant to inform you about the implications of signing the Power of Attorney. It emphasizes the importance of understanding the document fully and encourages you to seek legal advice if you have questions.
Will my agent have access to my medical records?
Yes, your agent will have the same access to your medical records as you do. This includes the authority to disclose information to others as necessary for your care.
How long does the Power of Attorney remain in effect?
The Power of Attorney remains in effect until your death unless you specify an earlier termination date or revoke it. Your agent will retain authority to make decisions even after you become disabled, as long as the document is valid.

Common mistakes

Filling out the Illinois Short Power of Attorney for Health Care can be a straightforward process, but many people make common mistakes that can lead to significant issues later. Understanding these pitfalls is crucial for ensuring that your health care wishes are respected.

One frequent mistake is failing to clearly identify the agent. When you fill out the form, you must provide the full name and address of your chosen agent. Leaving this information incomplete can result in confusion or disputes about who is authorized to make decisions on your behalf.

Another common error is neglecting to revoke prior powers of attorney. If you do not explicitly state that previous powers of attorney are revoked, they may still be considered valid. This can create conflicting instructions and complicate decision-making during critical times.

Some individuals forget to initial the anatomical gift section. If you do not indicate your wishes regarding organ donation, it will be assumed that you do not want to grant this authority to your agent. This oversight can prevent your agent from acting according to your desires.

People often overlook the importance of specifying limitations on the agent's powers. If you have particular wishes about life-sustaining treatment or other medical decisions, you must clearly outline these preferences in the designated section. Failing to do so may lead to decisions that do not align with your values.

Additionally, many signers do not read the notice at the beginning of the form carefully. This notice contains essential information about the powers you are granting and the responsibilities of your agent. Ignoring this notice can lead to misunderstandings about the scope of the authority you are giving.

Another mistake is not dating the form correctly. The power of attorney becomes effective on the date you specify. If you leave this blank or write an incorrect date, it can create confusion about when your agent can begin making decisions on your behalf.

Some individuals also fail to consider the implications of naming successor agents. If your primary agent is unavailable, you must ensure that you have designated successors properly. Not doing so can leave a gap in decision-making authority during critical moments.

Lastly, many people forget to sign the document. Without your signature, the power of attorney is not valid. This simple oversight can nullify your intentions, leaving your health care decisions in limbo.

By being aware of these common mistakes, you can take the necessary steps to ensure that your Illinois Short Power of Attorney for Health Care is filled out correctly. It is essential to approach this process with care and consideration to safeguard your health care wishes.

Documents used along the form

The Illinois Short Power of Attorney for Health Care is an important document that allows you to designate someone to make medical decisions on your behalf. When preparing this document, it is often beneficial to consider other forms and documents that complement it. Here are four additional forms that are commonly used alongside the Illinois Short Power of Attorney for Health Care.

Living Will: A living will outlines your preferences regarding medical treatment in situations where you are unable to communicate your wishes. This document typically specifies whether you want life-sustaining treatment, such as resuscitation or mechanical ventilation, in the event of a terminal illness or irreversible condition. It serves as a guide for your agent and healthcare providers, ensuring that your wishes are honored.
Durable Power of Attorney for Finances: This document allows you to appoint someone to manage your financial affairs if you become incapacitated. It grants your agent the authority to handle tasks such as paying bills, managing investments, and making financial decisions on your behalf. Having both a health care and financial power of attorney ensures comprehensive support during challenging times.
HIPAA Release Form: A Health Insurance Portability and Accountability Act (HIPAA) release form allows your designated agent to access your medical records and health information. This document is crucial for ensuring that your agent can make informed decisions about your care. It helps to facilitate communication between your healthcare providers and your agent, ensuring that they have the necessary information to act in your best interest.
Advance Directive: An advance directive is a broader term that encompasses both living wills and powers of attorney for health care. It provides a comprehensive plan for your medical care preferences and decision-making authority. This document can include specific instructions about your treatment preferences, organ donation, and end-of-life care, making it an essential part of your healthcare planning.

By considering these additional documents, you can create a more complete plan that addresses both your health care and financial needs. Each form plays a vital role in ensuring that your wishes are respected and that your designated agents can act effectively on your behalf when necessary.

Similar forms

Durable Power of Attorney: Similar to the Illinois Short Power form, a Durable Power of Attorney allows an individual to designate an agent to make decisions on their behalf. However, it typically covers a broader range of financial and legal matters, not just health care decisions.
Health Care Proxy: This document specifically authorizes someone to make medical decisions for another person if they become incapacitated. Like the Illinois Short Power form, it focuses on health care but may not include provisions for anatomical gifts or autopsy decisions.
Living Will: A Living Will outlines an individual's wishes regarding medical treatment in situations where they cannot communicate their preferences. While the Illinois Short Power form grants authority to an agent, a Living Will directly states the individual’s treatment preferences.
Advance Directive: An Advance Directive combines elements of both a Living Will and a Health Care Proxy. It allows individuals to express their medical treatment preferences and appoint an agent, similar to the Illinois Short Power form, but it may encompass a wider range of health care decisions.
Do Not Resuscitate (DNR) Order: A DNR order specifically instructs medical personnel not to perform CPR if a person stops breathing or their heart stops. While the Illinois Short Power form empowers an agent to make such decisions, a DNR focuses solely on resuscitation efforts.
Anatomical Gift Form: This document allows an individual to specify their wishes regarding organ donation after death. The Illinois Short Power form includes provisions for anatomical gifts but may not serve as a standalone document for organ donation preferences.
Declaration for Mental Health Treatment: This declaration allows individuals to appoint someone to make mental health treatment decisions on their behalf. Similar to the Illinois Short Power form, it emphasizes the importance of selecting a trusted agent, but it is specifically tailored for mental health matters.

Dos and Don'ts

When filling out the Illinois Short Power of Attorney for Health Care form, it is crucial to follow specific guidelines to ensure that the document serves its intended purpose effectively. Here are five essential dos and don'ts:

Do read the entire form carefully before signing. Understanding the implications of the document is vital.
Do choose an agent you trust completely. This person will make significant health care decisions on your behalf.
Do specify any limitations or specific wishes regarding your health care. This helps guide your agent's decisions.
Do initial any statements regarding life-sustaining treatment that reflect your wishes. This provides clarity for your agent.
Do keep a copy of the signed document in a safe place and share it with your agent and family members.

Don't leave any sections blank. Incomplete information may lead to confusion or misinterpretation of your wishes.
Don't name co-agents. The form specifically prohibits this, so choose only one agent.
Don't sign the document if you do not fully understand its contents. Seek legal advice if necessary.
Don't forget to date and sign the form. Without your signature, the document is not valid.
Don't assume that your agent knows your wishes without clear communication. Discuss your preferences with them.

Misconceptions

Understanding the Illinois Short Power of Attorney for Health Care is essential for making informed decisions about your medical care. However, several misconceptions often arise regarding this important document. Here are four common misconceptions:

Misconception 1: The agent must make decisions exactly as the principal would.

This is not entirely accurate. While the agent should strive to make decisions in alignment with the principal’s wishes, they are not legally bound to do so. The agent has the discretion to make choices based on their understanding of the principal's desires and best interests.

Misconception 2: The Illinois Short Power of Attorney for Health Care is only necessary for elderly individuals.

This misconception overlooks the fact that anyone, regardless of age, can experience a medical emergency or become incapacitated. Therefore, having this document in place is a prudent decision for adults of all ages.

Misconception 3: Once signed, the document cannot be changed or revoked.

Contrary to this belief, the principal retains the right to revoke or amend the power of attorney at any time, as long as they are mentally competent. This flexibility allows for adjustments based on changing circumstances or preferences.

Misconception 4: The agent has unlimited power over all health care decisions.

This is misleading. While the agent does have broad authority to make health care decisions, the principal can specify limitations within the document. It is crucial to articulate any restrictions or specific instructions to ensure the agent acts within the desired boundaries.

Key takeaways

Understanding the Illinois Short Power of Attorney for Health Care is essential for making informed decisions about your health care preferences. Here are some key takeaways:

Agent Selection is Crucial: Choose someone you trust as your agent. This person will have significant authority over your health care decisions, including end-of-life choices.
Broad Powers Granted: Your agent can make a wide range of health care decisions on your behalf, from consenting to treatment to deciding on hospitalization.
Record Keeping Required: Your agent is obligated to keep a record of significant actions taken on your behalf, ensuring accountability.
Revocation is Possible: You have the right to revoke the power of attorney at any time, giving you control over your health care decisions.
Understand Before Signing: Read the entire form carefully and ensure you understand it. If anything is unclear, consult a lawyer before signing.

By keeping these points in mind, you can navigate the process of creating a power of attorney with confidence and clarity.