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Illinois Health Care Power of Attorney Form

The Illinois health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Illinois Health Care Power of Attorney Form
Illinois Health Care Power of Attorney Form
POWER OF ATTORNEY FOR HEALTH CARE
ILLINOIS 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
POWERS ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE TO ACT
FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM AND KEEP A
RECORD OF RECEIPTS, DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS
AGENT. 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 (SEE THE
BACK OF THIS FORM). 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
Illinois Health Care Power of Attorney Form
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