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Statutory Short Form Power of Attorney for Health Care, Illinois |
$25.00 |
| This is a form of the Illinois Statutory Short Form Power of Attorney for Health Care. It allows you to appoint an agent for health care decisions and provides space to include specific instructions for your health care should you be unable to make health care decisions for yourself. It includes written instructions regarding life-sustaining or death delaying treatment. It also provides space to give specific instructions limiting the authority of the agent.
Format: |
Microsoft WordSTATUTORY SHORT FORM
POWER OF ATTORNEY FOR HEALTH CARE
(755 ILCS 45/4-10)
POWER OF ATTORNEY made this __ day of _____________, 20__.
1. I, ____________________________, residing at ___________________
_____________________________________________________________
(insert name and address of principal)
hereby appoint:
Name: ________________________________________________________
Address: ________________________________________________________
Phone: (home)_____________(cell) _____________ (work) ______________
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. My agent shall have the same access to my medical records that I have, including the right to disclose the contents to others. My agent shall also have full power to authorize an autopsy and direct the disposition of my remains.
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 you deem appropriate), such as: (1) your own definition of when life-sustaining measures should be withheld; (2) a direction to continue food and fluids or life-sustaining treatment in all events; or (3) instructions 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, amputation, psychosurgery, voluntary
admission to a mental institution, etc.):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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This is only a partial view of this document. Statutory Short Form Power of Attorney for Health Care, Illinois is just $25.00 and can be immediately downloaded after purchase. |
