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Blank Illinois Short Power PDF Form

The Illinois Short Power of Attorney for Health Care is a legal document that allows individuals to appoint an agent to make health care decisions on their behalf. This form grants broad authority to the designated agent, including the ability to consent to or withdraw medical treatment and make end-of-life decisions. Understanding the implications of this form is crucial, so consider filling it out by clicking the button below.

Article Guide

The Illinois Short Power of Attorney for Health Care is a crucial legal document that empowers individuals to designate an agent to make health care decisions on their behalf. This form is governed by the Illinois Power of Attorney Act and serves to ensure that one's medical preferences are honored, particularly in situations where they may be unable to communicate their wishes. By signing this form, the principal grants their agent the authority to make comprehensive decisions regarding medical treatment, hospitalization, and even end-of-life care. Importantly, the principal can specify successor agents but cannot appoint co-agents. The document emphasizes the importance of selecting a trustworthy agent, as they will have significant control over the principal's health care choices. It also outlines the agent's responsibilities, including acting in good faith and maintaining records of significant actions taken. The powers conferred by this document remain effective throughout the principal's lifetime unless revoked or limited. Furthermore, it is essential for individuals to understand the implications of this form, including their rights to amend or revoke it, as well as the legal protections for both the principal and the agent involved. This overview underscores the significance of the Illinois Short Power of Attorney for Health Care in facilitating informed and respectful health care decision-making.

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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

➤ PDF File

Form Specifications

Fact Name	Details
Governing Law	This form is governed by the Illinois Power of Attorney Act.
Agent Authority	The agent has broad powers to make health care decisions, including consent to or withdrawal of treatment.
Successor Agents	While you can name successor agents, co-agents are not permitted under this form.
Agent's Duty	Your agent must act in good faith and in accordance with your wishes and the law.
Record Keeping	Your agent is required to maintain a record of significant actions taken on your behalf.
Revocation	You can revoke this Power of Attorney at any time if you choose to do so.
Effective Date	The power of attorney becomes effective upon your specified date or event, such as a physician's determination of incapacity.
Termination	This power of attorney will terminate upon a specified date or event, such as a court determination of your capacity.

Illinois Short Power: Usage Guidelines

Filling out the Illinois Short Power of Attorney for Health Care form involves several steps to ensure that the designated agent can make health care decisions on behalf of the principal. It is crucial to follow each step carefully, as this document grants significant authority over medical decisions. Below are the steps to complete the form.

Read the notice at the beginning of the form carefully. Understand the implications of signing the document.
Initial the line provided to indicate that you have read the notice.
In the first section, fill in your name and address as the principal.
Appoint your agent by writing their name and address in the designated space. Remember, you cannot name co-agents.
Decide on anatomical gifts. Initial one of the options regarding organ donation or indicate that you do not grant authority for anatomical gifts.
Indicate whether your agent has the power to authorize an autopsy and direct the disposition of your remains.
Specify how your agent will handle your health information under HIPAA. Ensure your agent is authorized to access your medical records.
List any specific limitations or rules regarding the powers granted to your agent in the appropriate section.
Choose one of the provided statements regarding life-sustaining treatment and initial it. You may only initial one statement.
Indicate when this power of attorney will become effective by inserting a future date or event.
Specify when the power of attorney will terminate by inserting a future date or event, if desired.
Name successor agents in the provided section, if applicable. Provide their names and addresses.
If applicable, indicate whether you nominate your agent as guardian of your person by retaining the relevant paragraph.
Sign and date the form at the bottom to validate it.

Your Questions, Answered

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 an individual (the principal) to designate another person (the agent) to make health care decisions on their behalf. This includes decisions about medical treatment, hospitalization, and end-of-life care. The form is governed by the Illinois Power of Attorney Act.

What powers does the agent have under this form?

The agent has broad powers to make health care decisions for the principal. This includes the ability to consent to, withdraw, or withhold medical treatment, as well as the authority to admit or discharge the principal from health care facilities. The agent also has access to the principal's medical records and can make decisions regarding anatomical gifts and the disposition of remains after death.

Can I name more than one agent using this form?

No, the Illinois Short Power of Attorney for Health Care does not allow for the appointment of co-agents. The principal can only designate one agent at a time. However, the principal may name successor agents to act in case the primary agent is unable to fulfill their duties.

How long does the power of attorney remain in effect?

Unless specifically limited by the principal, the power of attorney remains effective throughout the principal's lifetime, even if the principal becomes disabled. The agent's authority continues until the principal revokes it or until the principal's death. Certain powers, such as those related to anatomical gifts and disposition of remains, remain in effect even after death.

Can the principal revoke the power of attorney?

Yes, the principal has the right to revoke the power of attorney at any time. Revocation must be done in writing and delivered to the agent and any relevant health care providers. It is important for the principal to communicate their wishes clearly to ensure that the revocation is honored.

What should I consider when choosing an agent?

It is crucial to select an agent whom you trust to make health care decisions that align with your values and wishes. The agent should be someone who is willing to take on this responsibility and is capable of making difficult decisions, especially in critical situations. Consider discussing your preferences and values with the agent before appointing them.

Are there any limitations I can place on the agent's powers?

Yes, the principal can specify limitations on the agent's powers within the form. This may include restrictions on certain types of medical treatments or conditions under which life-sustaining measures should be withheld. It is essential to clearly articulate any limitations to ensure the agent understands the principal's wishes.

What happens if the agent is unable to serve?

If the designated agent is unable to serve due to death, incompetence, or refusal, the principal can name successor agents in the form. These successors will have the authority to act on behalf of the principal in the order specified. It is advisable to ensure that successor agents are also trustworthy and willing to take on this responsibility.

What should I do if I have questions about the form?

If there are any uncertainties regarding the Illinois Short Power of Attorney for Health Care, it is recommended to consult with a lawyer. A legal professional can provide clarification on the document's implications and help ensure that the principal's wishes are accurately reflected in the form.

Common mistakes

Not Reading the Notice Carefully: Many individuals rush through the notice at the beginning of the form. This notice contains crucial information about the powers being granted and the responsibilities of the agent. It’s essential to understand what you are signing.
Failing to Name a Trustworthy Agent: Selecting an agent who is not trustworthy can lead to decisions that may not align with your wishes. It is vital to choose someone who understands your values and will act in your best interest.
Ignoring the Need for Successor Agents: Some people forget to name successor agents. If your primary agent is unable to act, having a backup ensures that someone can make decisions on your behalf.
Not Initialing Anatomical Gift Options: The section on anatomical gifts requires your initials. If you skip this step, it may be assumed that you do not wish to grant authority for such decisions.
Leaving Sections Blank: Incomplete forms can lead to confusion and may not be honored. Make sure to fill out all relevant sections, including any limitations or specific instructions you want to include.
Not Specifying Effective Dates: Many people forget to indicate when the power of attorney becomes effective. Clearly stating a date or event is crucial for ensuring your wishes are followed at the right time.
Neglecting to Understand Life-Sustaining Treatment Options: The form includes critical statements about life-sustaining treatment. Failing to initial one of these statements can lead to decisions that may not reflect your desires regarding medical treatment.
Not Revoking Previous Powers of Attorney: If you have existing powers of attorney, failing to revoke them can create conflicts. Make sure to clearly revoke any prior documents to avoid confusion.

Documents used along the form

The Illinois Short Power of Attorney for Health Care is a crucial document that allows individuals to designate someone to make medical decisions on their behalf. When creating or managing this document, several other forms may also be relevant. Below is a list of some commonly used forms and documents that often accompany the Illinois Short Power form.

Living Will: This document outlines an individual's wishes regarding medical treatment in situations where they are unable to communicate their preferences. It specifies the types of life-sustaining treatments a person does or does not want, providing guidance to healthcare providers and family members.
Durable Power of Attorney for Finances: This form allows an individual to appoint someone to manage their financial affairs if they become incapacitated. It complements the health care power of attorney by ensuring that both health and financial decisions are covered.
HIPAA Authorization Form: This document permits the sharing of an individual's medical information with specific people. It is essential for ensuring that the designated agent can access necessary health records to make informed decisions.
Advance Directive: This broader term encompasses both living wills and health care power of attorney. It provides a comprehensive set of instructions regarding a person's health care preferences and who should make decisions on their behalf.
Do Not Resuscitate (DNR) Order: This medical order instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a person stops breathing or their heart stops. It is particularly relevant for individuals with terminal illnesses or those who wish to avoid aggressive medical interventions.

Understanding these documents can enhance the effectiveness of the Illinois Short Power of Attorney for Health Care. Each serves a unique purpose, ensuring that an individual's medical and financial wishes are respected and upheld during critical times.

Similar forms

Durable Power of Attorney for Health Care: Similar to the Illinois Short Power form, this document allows you to designate an agent to make health care decisions on your behalf. It remains effective even if you become incapacitated.
Living Will: This document outlines your wishes regarding medical treatment in situations where you cannot communicate. It works alongside the power of attorney by providing guidance to your agent.
Health Care Proxy: Like the Illinois Short Power form, a health care proxy allows you to appoint someone to make health care decisions for you, ensuring your preferences are respected when you cannot express them.
Advance Directive: This document combines elements of a living will and a power of attorney, providing instructions for medical care and appointing an agent to make decisions on your behalf.
Do Not Resuscitate (DNR) Order: While focused specifically on resuscitation efforts, a DNR order complements the Illinois Short Power form by ensuring your wishes regarding life-sustaining treatment are known.
Anatomical Gift Form: Similar in purpose, this form allows you to specify your wishes regarding organ donation, which can be included in the powers granted to your agent.
HIPAA Release Form: This document allows you to authorize someone to access your medical records. It aligns with the Illinois Short Power form by ensuring your agent can obtain necessary health information.
State-Specific Power of Attorney Forms: Many states offer their own versions of power of attorney forms for health care, which share similarities with the Illinois Short Power form in terms of granting decision-making authority.
Mental Health Power of Attorney: This document specifically addresses decisions related to mental health care, allowing you to appoint an agent to make those choices, similar to the broader health care powers granted in the Illinois Short Power form.

Dos and Don'ts

When filling out the Illinois Short Power of Attorney form, there are important guidelines to follow. Here are four things you should and shouldn’t do:

Do read the entire form carefully before signing. Understanding the powers you are granting is crucial.
Do choose an agent you trust completely. This person will make significant health care decisions on your behalf.
Don’t sign the form if you have any doubts or questions. Seek legal advice to clarify any uncertainties.
Don’t name co-agents. The form specifically prohibits naming more than one agent at a time.

Misconceptions

Misconceptions about the Illinois Short Power of Attorney for Health Care can lead to confusion and misinformed decisions. Here are six common misconceptions:

Misconception 1: The agent has to be a family member.

This is not true. You can choose anyone as your agent, as long as they are an adult and you trust them to make health care decisions on your behalf.

Misconception 2: The form only applies if I am incapacitated.

The Illinois Short Power of Attorney for Health Care can be effective even while you are still capable of making your own decisions. It allows your agent to make choices when you are unable to communicate your wishes.

Misconception 3: I can name co-agents.

Under this form, you cannot name co-agents. You can appoint one primary agent and name successors if needed.

Misconception 4: The agent must follow my wishes exactly.

Your agent is required to act in good faith and make decisions that align with your known wishes. However, they also have the discretion to make choices based on your best interests if your wishes are unclear.

Misconception 5: The power of attorney cannot be revoked.

You can revoke the Illinois Short Power of Attorney for Health Care at any time, as long as you do so in writing and communicate this to your agent and health care providers.

Misconception 6: This form limits my medical treatment options.

The form does not limit your treatment options. Instead, it provides a way for your agent to make decisions based on your preferences, including the ability to withhold or withdraw treatment if that aligns with your wishes.

Key takeaways

When considering the Illinois Short Power of Attorney for Health Care, it’s essential to understand its implications and requirements. Here are some key takeaways:

Legal Document: This form is a legally binding document governed by the Illinois Power of Attorney Act. Always read it carefully.
Agent Authority: By signing, you grant your designated agent broad powers to make health care decisions on your behalf, including life-sustaining treatment choices.
Successor Agents: You can name successor agents, but co-agents are not permitted. Choose someone you trust to act in your best interest.
Revocation Rights: You have the right to revoke this Power of Attorney at any time, as long as you do so in writing.
Record Keeping: Your agent is required to keep a record of significant actions taken on your behalf, ensuring accountability.
Effective Duration: The Power of Attorney remains effective throughout your lifetime unless you specify a termination date or event.
Health Information Access: Your agent will have access to your medical records and can authorize their disclosure to third parties.
Consideration of Wishes: You can include specific instructions about your health care preferences, particularly regarding life-sustaining treatments.

Understanding these aspects can help you make informed decisions about your health care planning and ensure that your wishes are respected.