12/16/2014

ILLINOISDURABLEPOWEROFATTORNEYFORM

ILLINOISDURABLEPOWEROFATTORNEYFORM

POWEROFATTORNEYmadethis_________dayof____________________
(month)(year)
1. I,_____________________________________________________________
(insertnameandaddressofprincipal)
herebyappoint:
________________________________________________________________________
(insertnameandaddressofagent)
asmyattorneyinfact(my"agent")toactformeandinmyname(inanywayIcouldactinperson)tomakeanyandalldecisionsformeconcerningmypersonalcare,
medicaltreatment,hospitalizationandhealthcareandtorequire,withholdorwithdrawanytypeofmedicaltreatmentorprocedure,eventhoughmydeathmayensue.My
agentshallhavethesameaccesstomymedicalrecordsthatIhave,includingtherighttodisclosethecontentstoothers.Myagentshallalsohavefullpowertomakea
dispositionofanypartorallofmybodyformedicalpurposes,authorizeanautopsyanddirectthedispositionofmyremains.
(THEABOVEGRANTOFPOWERISINTENDEDTOBEASBROADASPOSSIBLESOTHATYOURAGENTWILLHAVEAUTHORITYTOMAKEANY
DECISIONYOUCOULDMAKETOOBTAINORTERMINATEANYTYPEOFHEALTHCARE,INCLUDINGWITHDRAWALOFFOODANDWATERAND
OTHERLIFESUSTAININGMEASURES,IFYOURAGENTBELIEVESSUCHACTIONWOULDBECONSISTENTWITHYOURINTENTANDDESIRES.IF
YOUWISHTOLIMITTHESCOPEOFYOURAGENTSPOWERSORPRESCRIBESPECIALRULESORLIMITTHEPOWERTOMAKEANANATOMICAL
GIFT,AUTHORIZEAUTOPSYORDISPOSEOFREMAINS,YOUMAYDOSOINTHEFOLLOWINGPARAGRAPHS.)
2.Thepowersgrantedaboveshallnotincludethefollowingpowersorshallbesubjecttothefollowingrulesorlimitations(hereyoumayincludeanyspecificlimitations
you deem appropriate, such as: your own definition of when lifesustaining measures should be withheld a direction to continue food and fluids or lifesustaining
treatment in all events or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other
reason,suchasbloodtransfusion,electroconvulsivetherapy,amputation,psychosurgery,voluntaryadmissiontoamentalinstitution,etc.):

_________________________________________________________________________________________________________________________________________________
(THE SUBJECT OF LIFESUSTAINING TREATMENT IS OF PARTICULAR IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT
SUBJECT, SOME GENERAL STATEMENTS CONCERNING THE WITHHOLDING OR REMOVAL OF LIFESUSTAINING TREATMENT ARE SET FORTH
BELOW.IFYOUAGREEWITHONEOFTHESESTATEMENTS,YOUMAYINITIALTHATSTATEMENTBUTDONOTINITIALMORETHANONE):
IdonotwantmylifetobeprolongednordoIwantlifesustainingtreatmenttobeprovidedorcontinuedifmyagentbelievestheburdensofthetreatmentoutweighthe
expectedbenefits.Iwantmyagenttoconsiderthereliefofsuffering,theexpenseinvolvedandthequalityaswellasthepossibleextensionofmylifeinmakingdecisions
concerninglifesustainingtreatment.
Initialed___________________
I want my life to be prolonged and I want lifesustaining treatment to be provided or continued unless I am in a coma which my attending physician believes to be
irreversible,inaccordancewithreasonablemedicalstandardsatthetimeofreference.IfandwhenIhavesufferedirreversiblecoma,Iwantlifesustainingtreatmenttobe
withheldordiscontinued.
Initialed___________________
Iwantmylifetobeprolongedtothegreatestextentpossiblewithoutregardtomycondition,thechancesIhaveforrecoveryorthecostoftheprocedures.
Initialed___________________
(THISPOWEROFATTORNEYMAYBEAMENDEDORREVOKEDBYYOUINTHEMANNERPROVIDEDINSECTION46OFTHEILLINOIS"POWERS
OFATTORNEYFORHEALTHCARELAW"(SEETHEBACKOFTHISFORM)ABSENTAMENDMENTORREVOCATION,THEAUTHORITYGRANTEDIN
THISPOWEROFATTORNEYWILLBECOMEEFFECTIVEATTHETIMETHISPOWERISSIGNEDANDWILLCONTINUEUNTILYOURDEATH,AND
BEYONDIFANATOMICALGIFT,AUTOPSYORDISPOSITIONOFREMAINSISAUTHORIZED,UNLESSALIMITATIONONTHEBEGINNINGDATEOR
DURATIONISMADEBYINITIALINGANDCOMPLETINGEITHERORBOTHOFTHEFOLLOWING:)
1. ()Thispowerofattorneyshallbecomeeffectiveon________________
____________________________________________________________________
____________________________________________________________________
(insertafuturedateoreventduringyourlifetime,suchasacourtdeterminationofyourdisability,whenyouwantthispowertofirsttakeeffect)

1. ()Thispowerofattorneyshallterminateon_____________________
___________________________________________________________________
(insertafuturedateorevent,suchasacourtdeterminationofyourdisability,whenyouwantthispowertoterminatepriortoyourdeath)
(IFYOUWISHTONAMESUCCESSORAGENTS,INSERTTHENAMESANDADDRESSESOFSUCHSUCCESSORSINTHEFOLLOWINGPARAGRAPH.)
1. Ifanyagentnamedbymeshalldie,becomeincompetent,resign,refusetoaccepttheofficeofagentorbeunavailable,Inamethefollowing(eachtoact
aloneandsuccessively,intheordernamed)assuccessorstosuchagent:
________________________________________________________________________________________________________________________________________________
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12/16/2014

ILLINOISDURABLEPOWEROFATTORNEYFORM

Forpurposesofthisparagraph5,apersonshallbeconsideredtobeincompetentifandwhilethepersonisaminororanadjudicatedincompetentordisabledpersonor
thepersonisunabletogivepromptandintelligentconsiderationtohealthcarematters,ascertifiedbyalicensedphysician.
(IFYOUWISHTONAMEYOURAGENTASGUARDIANOFYOURPERSON,INTHEEVENTACOURTDECIDESTHATONESHOULDBEAPPOINTED,
YOUMAY,BUTARENOTREQUIREDTO,DOSOBYRETAININGTHEFOLLOWINGPARAGRAPH.THECOURTWILLAPPOINTYOURAGENTIFTHE
COURT FINDS THAT SUCH APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND WELFARE. STRIKE OUT PARAGRAPH 6 IF YOU DO NOT
WANTYOURAGENTTOACTASGUARDIAN.)
6. Ifaguardianofmypersonistobeappointed,Inominatetheagentactingunderthispowerofattorneyassuchguardian,toservewithoutbondorsecurity.
7. Iamfullyinformedastoallthecontentsofthisformandunderstandthefullimportofthisgrantofpowerstomyagent.
Signed__________________________________
(principal)
Theprincipalhashadanopportunitytoreadtheaboveformandhassignedtheformoracknowledgedhisorhersignatureormarkontheforminmypresence.

_________________________Residingat____________________________________
(witness)
(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF
YOUINCLUDESPECIMENSIGNATURESINTHISPOWEROFATTORNEY,YOUMUSTCOMPLETETHECERTIFICATIONOPPOSITETHESIGNATURES
OFTHEAGENTS.)

SpecimensignaturesofIcertifythatthesignaturesofmyagent(andsuccessors).ofmyagent(andsuccessors)
arecorrect

_________________________________________________________________
(agent)(principal)
___________________________________________________________________
(successoragent)(principal)
___________________________________________________________________
(successoragent)(principal)

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