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| Public Act 098-1113 | ||||
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AN ACT concerning civil law.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Power of Attorney Act is amended by | ||||
changing Sections 4-4, 4-5, 4-5.1, 4-10, and 4-12 as follows:
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(755 ILCS 45/4-4) (from Ch. 110 1/2, par. 804-4)
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Sec. 4-4. Definitions. As used in this Article:
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(a) "Attending physician" means the physician who has | ||||
primary
responsibility at the time of reference for the | ||||
treatment and care of the patient.
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(b) "Health care" means any care, treatment, service or | ||||
procedure to
maintain, diagnose, treat or provide for the | ||||
patient's physical or mental
health or personal care.
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(c) "Health care agency" means an agency governing any type | ||||
of health
care, anatomical gift, autopsy or disposition of | ||||
remains for and on behalf
of a patient and refers to the power | ||||
of attorney or other written
instrument defining the agency or | ||||
the agency, itself, as appropriate to the context.
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(d) "Health care provider", "health care professional", or | ||||
"provider" means the attending physician
and any other person | ||||
administering health care to the patient at the time
of | ||||
reference who is licensed, certified, or otherwise authorized | ||||
or
permitted by law to administer health care in the ordinary | ||||
course of
business or the practice of a profession, including | ||
any person employed by
or acting for any such authorized | ||
person.
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(e) "Patient" means the principal or, if the agency governs | ||
health care
for a minor child of the principal, then the child.
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(e-5) "Health care agent" means an individual at least 18 | ||
years old designated by the principal to make health care | ||
decisions of any type, including, but not limited to, | ||
anatomical gift, autopsy, or disposition of remains for and on | ||
behalf of the individual. A health care agent is a personal | ||
representative under state and federal law. The health care | ||
agent has the authority of a personal representative under both | ||
state and federal law unless restricted specifically by the | ||
health care agency. | ||
(f) (Blank). "Incurable or irreversible condition" means | ||
an illness or injury (i) for which there is no reasonable | ||
prospect of cure or recovery, (ii) that ultimately will cause | ||
the patient's death even if life-sustaining treatment is | ||
initiated or continued, (iii) that imposes severe pain or | ||
otherwise imposes an inhumane burden on the patient, or (iv) | ||
for which initiating or continuing life-sustaining treatment, | ||
in light of the patient's medical condition, provides only | ||
minimal medical benefit. | ||
(g) (Blank). "Permanent unconsciousness" means a condition | ||
that, to a high degree of medical certainty, (i) will last | ||
permanently, without improvement, (ii) in which thought, | ||
sensation, purposeful action, social interaction, and | ||
awareness of self and environment are absent, and (iii) for | ||
which initiating or continuing life-sustaining treatment, in | ||
light of the patient's medical condition, provides only minimal | ||
medical benefit. For the purposes of this definition, "medical | ||
benefit" means a chance to cure or reverse a condition. | ||
(h) (Blank). "Terminal condition" means an illness or | ||
injury for which there is no reasonable prospect of cure or | ||
recovery, death is imminent, and the application of | ||
life-sustaining treatment would only prolong the dying | ||
process. | ||
(Source: P.A. 96-1195, eff. 7-1-11.)
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(755 ILCS 45/4-5) (from Ch. 110 1/2, par. 804-5)
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Sec. 4-5. Limitations on health care agencies. Neither the | ||
attending
physician nor any other health care provider or | ||
health care professional may act as agent under a
health care | ||
agency; however, a person who is not administering health
care | ||
to the patient may act as health care agent for the patient | ||
even
though the person is a physician or otherwise licensed, | ||
certified,
authorized, or permitted by law to administer health | ||
care in the ordinary
course of business or the practice of a | ||
profession.
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(Source: P.A. 86-736.)
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(755 ILCS 45/4-5.1) | ||
Sec. 4-5.1. Limitations on who may witness health care | ||
agencies. | ||
(a) Every health care agency shall bear the signature of a | ||
witness to the signing of the agency. No witness may be under | ||
18 years of age. None of the following licensed professionals | ||
providing services to the principal may serve as a witness to | ||
the signing of a health care agency: | ||
(1) the attending physician, advanced practice nurse, | ||
physician assistant, dentist, podiatric physician, | ||
optometrist, or mental health service provider of the | ||
principal, or a relative of the physician, advanced | ||
practice nurse, physician assistant, dentist, podiatric | ||
physician, optometrist, or mental health service provider; | ||
(2) an owner, operator, or relative of an owner or | ||
operator of a health care facility in which the principal | ||
is a patient or resident; | ||
(3) a parent, sibling, or descendant, or the spouse of | ||
a parent, sibling, or descendant, of either the principal | ||
or any agent or successor agent, regardless of whether the | ||
relationship is by blood, marriage, or adoption; | ||
(4) an agent or successor agent for health care. | ||
(b) The prohibition on the operator of a health care | ||
facility from serving as a witness shall extend to directors | ||
and executive officers of an operator that is a corporate | ||
entity but not other employees of the operator such as, but not | ||
limited to, non-owner chaplains or social workers, nurses, and | ||
other employees.
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(Source: P.A. 96-1195, eff. 7-1-11.)
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(755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10)
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Sec. 4-10. Statutory short form power of attorney for | ||
health care.
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(a) The form prescribed in this Section (sometimes also | ||
referred to in this Act as the
"statutory health care power") | ||
may be used to grant an agent powers with
respect to the | ||
principal's own health care; but the statutory health care
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power is not intended to be exclusive nor to cover delegation | ||
of a parent's
power to control the health care of a minor | ||
child, and no provision of this
Article shall be construed to | ||
invalidate or bar use by the principal of any
other or
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different form of power of attorney for health care. | ||
Nonstatutory health
care powers must be
executed by the | ||
principal, designate the agent and the agent's powers, and
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comply with the limitations in Section 4-5 of this Article, but | ||
they need not be witnessed or
conform in any other respect to | ||
the statutory health care power. | ||
No specific format is required for the statutory health | ||
care power of attorney other than the notice must precede the | ||
form. When a
power of attorney in substantially the
form | ||
prescribed in this Section is used, including the "Notice to | ||
the Individual Signing the Illinois Statutory Short Form Power | ||
of Attorney for Health Care" (or "Notice" paragraphs) at the | ||
beginning of the form on a separate sheet in 14-point type, it | ||
shall have the meaning and effect prescribed in this
Act. A | ||
power of attorney for health care shall be deemed to be in | ||
substantially the same format as the statutory form if the | ||
explanatory language throughout the form (the language | ||
following the designation "NOTE:") is distinguished in some way | ||
from the legal paragraphs in the form, such as the use of | ||
boldface or other difference in typeface and font or point | ||
size, even if the "Notice" paragraphs at the beginning are not | ||
on a separate sheet of paper or are not in 14-point type, or if | ||
the principal's initials do not appear in the acknowledgement | ||
at the end of the "Notice" paragraphs. The statutory health | ||
care power may be included in or
combined with any
other form | ||
of power of attorney governing property or other matters.
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(b) The Illinois Statutory Short Form Power of Attorney for | ||
Health Care shall be substantially as follows: | ||
NOTICE TO THE INDIVIDUAL SIGNING | ||
THE POWER OF ATTORNEY FOR HEALTH CARE | ||
No one can predict when a serious illness or accident might | ||
occur. When it does, you may need someone else to speak or make | ||
health care decisions for you. If you plan now, you can | ||
increase the chances that the medical treatment you get will be | ||
the treatment you want. | ||
In Illinois, you can choose someone to be your "health care | ||
agent". Your agent is the person you trust to make health care | ||
decisions for you if you are unable or do not want to make them | ||
yourself. These decisions should be based on your personal | ||
values and wishes. | ||
It is important to put your choice of agent in writing. The | ||
written form is often called an "advance directive". You may | ||
use this form or another form, as long as it meets the legal | ||
requirements of Illinois. There are many written and on-line | ||
resources to guide you and your loved ones in having a | ||
conversation about these issues. You may find it helpful to | ||
look at these resources while thinking about and discussing | ||
your advance directive. | ||
WHAT ARE THE THINGS I WANT MY | ||
HEALTH CARE AGENT TO KNOW? | ||
The selection of your agent should be considered carefully, | ||
as your agent will have the ultimate decision making authority | ||
once this document goes into effect, in most instances after | ||
you are no longer able to make your own decisions. While the | ||
goal is for your agent to make decisions in keeping with your | ||
preferences and in the majority of circumstances that is what | ||
happens, please know that the law does allow your agent to make | ||
decisions to direct or refuse health care interventions or | ||
withdraw treatment. Your agent will need to think about | ||
conversations you have had, your personality, and how you | ||
handled important health care issues in the past. Therefore, it | ||
is important to talk with your agent and your family about such | ||
things as: | ||
(i) What is most important to you in your life? | ||
(ii) How important is it to you to avoid pain and | ||
suffering? | ||
(iii) If you had to choose, is it more important to you | ||
to live as long as possible, or to avoid prolonged | ||
suffering or disability? | ||
(iv) Would you rather be at home or in a hospital for | ||
the last days or weeks of your life? | ||
(v) Do you have religious, spiritual, or cultural | ||
beliefs that you want your agent and others to consider? | ||
(vi) Do you wish to make a significant contribution to | ||
medical science after your death through organ or whole | ||
body donation? | ||
(vii) Do you have an existing advanced directive, such | ||
as a living will, that contains your specific wishes about | ||
health care that is only delaying your death? If you have | ||
another advance directive, make sure to discuss with your | ||
agent the directive and the treatment decisions contained | ||
within that outline your preferences. Make sure that your | ||
agent agrees to honor the wishes expressed in your advance | ||
directive. | ||
WHAT KIND OF DECISIONS CAN MY AGENT MAKE? | ||
If there is ever a period of time when your physician | ||
determines that you cannot make your own health care decisions, | ||
or if you do not want to make your own decisions, some of the | ||
decisions your agent could make are to: | ||
(i) talk with physicians and other health care | ||
providers about your condition. | ||
(ii) see medical records and approve who else can see | ||
them. | ||
(iii) give permission for medical tests, medicines, | ||
surgery, or other treatments. | ||
(iv) choose where you receive care and which physicians | ||
and others provide it. | ||
(v) decide to accept, withdraw, or decline treatments | ||
designed to keep you alive if you are near death or not | ||
likely to recover. You may choose to include guidelines | ||
and/or restrictions to your agent's authority. | ||
(vi) agree or decline to donate your organs or your | ||
whole body if you have not already made this decision | ||
yourself. This could include donation for transplant, | ||
research, and/or education. You should let your agent know | ||
whether you are registered as a donor in the First Person | ||
Consent registry maintained by the Illinois Secretary of | ||
State or whether you have agreed to donate your whole body | ||
for medical research and/or education. | ||
(vii) decide what to do with your remains after you | ||
have died, if you have not already made plans. | ||
(viii) talk with your other loved ones to help come to | ||
a decision (but your designated agent will have the final | ||
say over your other loved ones). | ||
Your agent is not automatically responsible for your health | ||
care expenses. | ||
WHOM SHOULD I CHOOSE TO BE MY HEALTH CARE AGENT? | ||
You can pick a family member, but you do not have to. Your | ||
agent will have the responsibility to make medical treatment | ||
decisions, even if other people close to you might urge a | ||
different decision. The selection of your agent should be done | ||
carefully, as he or she will have ultimate decision-making | ||
authority for your treatment decisions once you are no longer | ||
able to voice your preferences. Choose a family member, friend, | ||
or other person who: | ||
(i) is at least 18 years old; | ||
(ii) knows you well; | ||
(iii) you trust to do what is best for you and is | ||
willing to carry out your wishes, even if he or she may not | ||
agree with your wishes; | ||
(iv) would be comfortable talking with and questioning | ||
your physicians and other health care providers; | ||
(v) would not be too upset to carry out your wishes if | ||
you became very sick; and | ||
(vi) can be there for you when you need it and is | ||
willing to accept this important role. | ||
WHAT IF MY AGENT IS NOT AVAILABLE OR IS | ||
UNWILLING TO MAKE DECISIONS FOR ME? | ||
If the person who is your first choice is unable to carry | ||
out this role, then the second agent you chose will make the | ||
decisions; if your second agent is not available, then the | ||
third agent you chose will make the decisions. The second and | ||
third agents are called your successor agents and they function | ||
as back-up agents to your first choice agent and may act only | ||
one at a time and in the order you list them. | ||
WHAT WILL HAPPEN IF I DO NOT | ||
CHOOSE A HEALTH CARE AGENT? | ||
If you become unable to make your own health care decisions | ||
and have not named an agent in writing, your physician and | ||
other health care providers will ask a family member, friend, | ||
or guardian to make decisions for you. In Illinois, a law | ||
directs which of these individuals will be consulted. In that | ||
law, each of these individuals is called a "surrogate". | ||
There are reasons why you may want to name an agent rather | ||
than rely on a surrogate: | ||
(i) The person or people listed by this law may not be | ||
who you would want to make decisions for you. | ||
(ii) Some family members or friends might not be able | ||
or willing to make decisions as you would want them to. | ||
(iii) Family members and friends may disagree with one | ||
another about the best decisions. | ||
(iv) Under some circumstances, a surrogate may not be | ||
able to make the same kinds of decisions that an agent can | ||
make. | ||
WHAT IF THERE IS NO ONE AVAILABLE | ||
WHOM I TRUST TO BE MY AGENT? | ||
In this situation, it is especially important to talk to | ||
your physician and other health care providers and create | ||
written guidance about what you want or do not want, in case | ||
you are ever critically ill and cannot express your own wishes. | ||
You can complete a living will. You can also write your wishes | ||
down and/or discuss them with your physician or other health | ||
care provider and ask him or her to write it down in your | ||
chart. You might also want to use written or on-line resources | ||
to guide you through this process. | ||
WHAT DO I DO WITH THIS FORM ONCE I COMPLETE IT? | ||
Follow these instructions after you have completed the | ||
form: | ||
(i) Sign the form in front of a witness. See the form | ||
for a list of who can and cannot witness it. | ||
(ii) Ask the witness to sign it, too. | ||
(iii) There is no need to have the form notarized. | ||
(iv) Give a copy to your agent and to each of your | ||
successor agents. | ||
(v) Give another copy to your physician. | ||
(vi) Take a copy with you when you go to the hospital. | ||
(vii) Show it to your family and friends and others who | ||
care for you. | ||
WHAT IF I CHANGE MY MIND? | ||
You may change your mind at any time. If you do, tell | ||
someone who is at least 18 years old that you have changed your | ||
mind, and/or destroy your document and any copies. If you wish, | ||
fill out a new form and make sure everyone you gave the old | ||
form to has a copy of the new one, including, but not limited | ||
to, your agents and your physicians. | ||
WHAT IF I DO NOT WANT TO USE THIS FORM? | ||
In the event you do not want to use the Illinois statutory | ||
form provided here, any document you complete must be executed | ||
by you, designate an agent who is over 18 years of age and not | ||
prohibited from serving as your agent, and state the agent's | ||
powers, but it need not be witnessed or conform in any other | ||
respect to the statutory health care power. | ||
If you have questions about the use of any form, you may | ||
want to consult your physician, other health care provider, | ||
and/or an attorney. | ||
MY POWER OF ATTORNEY FOR HEALTH CARE | ||
THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY | ||
FOR HEALTH CARE. (You must sign this form and a witness must | ||
also sign it before it is valid) | ||
My name (Print your full name):.............................. | ||
My address:.................................................. | ||
I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT | ||
(an agent is your personal representative under state and | ||
federal law): | ||
(Agent name)................................................. | ||
(Agent address).............................................. | ||
(Agent phone number)......................................... | ||
MY AGENT CAN MAKE HEALTH CARE DECISIONS FOR ME, INCLUDING: | ||
(i) Deciding to accept, withdraw or decline treatment | ||
for any physical or mental condition of mine, including | ||
life-and-death decisions. | ||
(ii) Agreeing to admit me to or discharge me from any | ||
hospital, home, or other institution, including a mental | ||
health facility. | ||
(iii) Having complete access to my medical and mental | ||
health records, and sharing them with others as needed, | ||
including after I die. | ||
(iv) Carrying out the plans I have already made, or, if | ||
I have not done so, making decisions about my body or | ||
remains, including organ, tissue or whole body donation, | ||
autopsy, cremation, and burial. | ||
The above grant of power is intended to be as broad as | ||
possible so that my agent will have the authority to make any | ||
decision I could make to obtain or terminate any type of health | ||
care, including withdrawal of nutrition and hydration and other | ||
life-sustaining measures. | ||
I AUTHORIZE MY AGENT TO (please check any one box): | ||
.... Make decisions for me only when I cannot make them for | ||
myself. The physician(s) taking care of me will determine | ||
when I lack this ability. | ||
(If no box is checked, then the box above shall be | ||
implemented.)
OR | ||
.... Make decisions for me starting now and continuing | ||
after I am no longer able to make them for myself. While I | ||
am still able to make my own decisions, I can still do so | ||
if I want to. | ||
The subject of life-sustaining treatment is of particular | ||
importance. Life-sustaining treatments may include tube | ||
feedings or fluids through a tube, breathing machines, and CPR. | ||
In general, in making decisions concerning life-sustaining | ||
treatment, your agent is instructed to consider the relief of | ||
suffering, the quality as well as the possible extension of | ||
your life, and your previously expressed wishes. Your agent | ||
will weigh the burdens versus benefits of proposed treatments | ||
in making decisions on your behalf. | ||
Additional statements concerning the withholding or | ||
removal of life-sustaining treatment are described below. | ||
These can serve as a guide for your agent when making decisions | ||
for you. Ask your physician or health care provider if you have | ||
any questions about these statements. | ||
SELECT ONLY ONE STATEMENT BELOW THAT BEST EXPRESSES YOUR WISHES | ||
(optional): | ||
.... The quality of my life is more important than the | ||
length of my life. If I am unconscious and my attending | ||
physician believes, in accordance with reasonable medical | ||
standards, that I will not wake up or recover my ability to | ||
think, communicate with my family and friends, and | ||
experience my surroundings, I do not want treatments to | ||
prolong my life or delay my death, but I do want treatment | ||
or care to make me comfortable and to relieve me of pain. | ||
.... Staying alive is more important to me, no matter how | ||
sick I am, how much I am suffering, the cost of the | ||
procedures, or how unlikely my chances for recovery are. I | ||
want my life to be prolonged to the greatest extent | ||
possible in accordance with reasonable medical standards. | ||
SPECIFIC LIMITATIONS TO MY AGENT'S DECISION-MAKING AUTHORITY: | ||
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. If you wish to limit the scope of your agent's | ||
powers or prescribe special rules or limit the power to | ||
authorize autopsy or dispose of remains, you may do so | ||
specifically in this form. | ||
| ............................................................. | ||
| ............................................................. | ||
My signature:................................................ | ||
Today's date:................................................ | ||
HAVE YOUR WITNESS AGREE TO WHAT IS WRITTEN BELOW, AND THEN | ||
COMPLETE THE SIGNATURE PORTION: | ||
I am at least 18 years old. (check one of the options | ||
below): | ||
.... I saw the principal sign this document, or | ||
.... the principal told me that the signature or mark on | ||
the principal signature line is his or hers. | ||
I am not the agent or successor agent(s) named in this | ||
document. I am not related to the principal, the agent, or the | ||
successor agent(s) by blood, marriage, or adoption. I am not | ||
the principal's physician, mental health service provider, or a | ||
relative of one of those individuals. I am not an owner or | ||
operator (or the relative of an owner or operator) of the | ||
health care facility where the principal is a patient or | ||
resident. | ||
Witness printed name:........................................ | ||
Witness address:............................................. | ||
Witness signature:........................................... | ||
Today's date:................................................ | ||
SUCCESSOR HEALTH CARE AGENT(S) (optional): | ||
If the agent I selected is unable or does not want to make | ||
health care decisions for me, then I request the person(s) I | ||
name below to be my successor health care agent(s). Only one | ||
person at a time can serve as my agent (add another page if you | ||
want to add more successor agent names): | ||
| ............................................................. | ||
(Successor agent #1 name, address and phone number) | ||
| ............................................................. | ||
(Successor agent #2 name, address and phone number) | ||
"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 benefit 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 significant actions taken | ||
as your agent. | ||
Unless you specifically 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 finds 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)" | ||
"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.
| ||
.... Specific 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. | ||
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 identifiable health information | ||
or other medical records, including records or communications | ||
governed by the Mental Health and Developmental Disabilities | ||
Confidentiality 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 defined 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 | ||
identifiable 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 Confidentiality 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 identifiable 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.)
| ||
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 specific limitations you deem | ||
appropriate, such as: your own
definition of when | ||
life-sustaining measures should be withheld; a direction
to | ||
continue food and fluids or life-sustaining 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, 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 benefits. 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 defined 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 ...........................
| ||
(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: 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 first take
effect.)
| ||
(NOTE: If you do not amend or revoke this power, or if you do | ||
not specify a specific 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: 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 office of agent or be unavailable, | ||
I name
the following (each to act alone
and successively, in | ||
the order named) as successors to such 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 certified 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 finds 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)
| ||
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 certifies 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, | ||
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 certification opposite the signatures of the | ||
agents.)
| ||
Specimen signatures of I certify that the signatures of my
| ||
agent (and successors). 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) | ||
......................... | ||
(phone) | ||
(c) The statutory short form power of attorney for health | ||
care (the
"statutory health care power") authorizes the agent | ||
to make any and all
health care decisions on behalf of the | ||
principal which the principal could
make if present and under | ||
no disability, subject to any limitations on the
granted powers | ||
that appear on the face of the form, to be exercised in such
| ||
manner as the agent deems consistent with the intent and | ||
desires of the
principal. The agent will be under no duty to | ||
exercise granted powers or
to assume control of or | ||
responsibility for the principal's health care;
but when | ||
granted powers are exercised, the agent will be required to use
| ||
due care to act for the benefit of the principal in accordance | ||
with the
terms of the statutory health care power and will be | ||
liable
for negligent exercise. The agent may act in person or | ||
through others
reasonably employed by the agent for that | ||
purpose
but may not delegate authority to make health care | ||
decisions. The agent
may sign and deliver all instruments, | ||
negotiate and enter into all
agreements and do all other acts | ||
reasonably necessary to implement the
exercise of the powers | ||
granted to the agent. Without limiting the
generality of the | ||
foregoing, the statutory health care power shall include
the | ||
following powers, subject to any limitations appearing on the | ||
face of the form:
| ||
(1) The agent is authorized to give consent to and | ||
authorize or refuse,
or to withhold or withdraw consent to, | ||
any and all types of medical care,
treatment or procedures | ||
relating to the physical or mental health of the
principal, | ||
including any medication program, surgical procedures,
| ||
life-sustaining treatment or provision of food and fluids | ||
for the principal.
| ||
(2) The agent is authorized to admit the principal to | ||
or discharge the
principal from any and all types of | ||
hospitals, institutions, homes,
residential or nursing | ||
facilities, treatment centers and other health care
| ||
institutions providing personal care or treatment for any | ||
type of physical
or mental condition. The agent shall have | ||
the same right to visit the
principal in the hospital or | ||
other institution as is granted to a spouse or
adult child | ||
of the principal, any rule of the institution to the | ||
contrary
notwithstanding.
| ||
(3) The agent is authorized to contract for any and all | ||
types of health
care services and facilities in the name of | ||
and on behalf of the principal
and to bind the principal to | ||
pay for all such services and facilities,
and to have and | ||
exercise those powers over the principal's property as are
| ||
authorized under the statutory property power, to the | ||
extent the agent
deems necessary to pay health care costs; | ||
and
the agent shall not be personally liable for any | ||
services or care contracted
for on behalf of the principal.
| ||
(4) At the principal's expense and subject to | ||
reasonable rules of the
health care provider to prevent | ||
disruption of the principal's health care,
the agent shall | ||
have the same right the principal has to examine and copy
| ||
and consent to disclosure of all the principal's medical | ||
records that the agent deems
relevant to the exercise of | ||
the agent's powers, whether the records
relate to mental | ||
health or any other medical condition and whether they are | ||
in
the possession of or maintained by any physician, | ||
psychiatrist,
psychologist, therapist, hospital, nursing | ||
home or other health care
provider. The authority under | ||
this paragraph (4) applies to any information governed by | ||
the Health Insurance Portability and Accountability Act of | ||
1996 ("HIPAA") and regulations thereunder. The agent | ||
serves as the principal's personal representative, as that | ||
term is defined under HIPAA and regulations thereunder.
| ||
(5) The agent is authorized: to direct that an autopsy | ||
be made pursuant
to Section 2 of "An Act in relation to | ||
autopsy of dead bodies", approved
August 13, 1965, | ||
including all amendments;
to make a disposition of any
part | ||
or all of the principal's body pursuant to the Illinois | ||
Anatomical Gift
Act, as now or hereafter amended; and to | ||
direct the disposition of the
principal's remains.
| ||
(Source: P.A. 96-1195, eff. 7-1-11; 97-148, eff. 7-14-11.)
| ||
(755 ILCS 45/4-12) (from Ch. 110 1/2, par. 804-12)
| ||
Sec. 4-12. Saving clause. This Act does not in any way
| ||
invalidate any health care agency executed or any act of any
| ||
agent done, or affect any claim, right or
remedy that accrued, | ||
prior to September 22, 1987.
| ||
This amendatory Act of the 96th General Assembly does not | ||
in any way invalidate any health care agency executed or any | ||
act of any agent done, or affect any claim, right, or remedy | ||
that accrued, prior to the effective date of this amendatory | ||
Act of the 96th General Assembly. | ||
This amendatory Act of the 98th General Assembly does not | ||
in any way invalidate any health care agency executed or any | ||
act of any agent done, or affect any claim, right, or remedy | ||
that accrued, prior to the effective date of this amendatory | ||
Act of the 98th General Assembly. | ||
(Source: P.A. 96-1195, eff. 7-1-11.)
| ||
Section 99. Effective date. This Act takes effect January | ||
1, 2015.
| ||