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91_HB0404enr HB0404 Enrolled LRB9101374DJcd 1 AN ACT to amend the Illinois Power of Attorney Act by 2 changing Section 4-10. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 Section 5. The Illinois Power of Attorney Act is 6 amended by changing Section 4-10 as follows: 7 (755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10) 8 Sec. 4-10. Statutory short form power of attorney for 9 health care. (a) The following form (sometimes also referred 10 to in this Act as the "statutory health care power") may be 11 used to grant an agent powers with respect to the principal's 12 own health care; but the statutory health care power is not 13 intended to be exclusive nor to cover delegation of a 14 parent's power to control the health care of a minor child, 15 and no provision of this Article shall be construed to 16 invalidate or bar use by the principal of any other or 17 different form of power of attorney for health care. 18 Nonstatutory health care powers must be executed by the 19 principal, designate the agent and the agent's powers, and 20 comply with Section 4-5 of this Article, but they need not be 21 witnessed or conform in any other respect to the statutory 22 health care power. When a power of attorney in substantially 23 the following form is used, including the "notice" paragraph 24 at the beginning in capital letters, it shall have the 25 meaning and effect prescribed in this Act. The statutory 26 health care power may be included in or combined with any 27 other form of power of attorney governing property or other 28 matters. 29 "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR 30 HEALTH CARE 31 (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO HB0404 Enrolled -2- LRB9101374DJcd 1 GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO 2 MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING POWER TO 3 REQUIRE, CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL CARE OR 4 MEDICAL TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO 5 ADMIT YOU TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR 6 OTHER INSTITUTION. THIS FORM DOES NOT IMPOSE A DUTY ON YOUR 7 AGENT TO EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE 8 EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE TO ACT FOR 9 YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM AND KEEP A 10 RECORD OF RECEIPTS, DISBURSEMENTS AND SIGNIFICANT ACTIONS 11 TAKEN AS AGENT. A COURT CAN TAKE AWAY THE POWERS OF YOUR 12 AGENT IF IT FINDS THE AGENT IS NOT ACTING PROPERLY. YOU MAY 13 NAME SUCCESSOR AGENTS UNDER THIS FORM BUT NOT CO-AGENTS, AND 14 NO HEALTH CARE PROVIDER MAY BE NAMED. UNLESS YOU EXPRESSLY 15 LIMIT THE DURATION OF THIS POWER IN THE MANNER PROVIDED 16 BELOW, UNTIL YOU REVOKE THIS POWER OR A COURT ACTING ON YOUR 17 BEHALF TERMINATES IT, YOUR AGENT MAY EXERCISE THE POWERS 18 GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME 19 DISABLED. THE POWERS YOU GIVE YOUR AGENT, YOUR RIGHT TO 20 REVOKE THOSE POWERS AND THE PENALTIES FOR VIOLATING THE LAW 21 ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND 22 4-10(b) OF THE ILLINOIS "POWERS OF ATTORNEY FOR HEALTH CARE 23 LAW" OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS 24 FORM). THAT LAW EXPRESSLY PERMITS THE USE OF ANY DIFFERENT 25 FORM OF POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS 26 ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU 27 SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.) 28 POWER OF ATTORNEY made this .......................day of 29 ................................ 30 (month) (year) 31 1. I, .................................................., 32 (insert name and address of principal) 33 hereby appoint: 34 ............................................................ HB0404 Enrolled -3- LRB9101374DJcd 1 (insert name and address of agent) 2 as my attorney-in-fact (my "agent") to act for me and in my 3 name (in any way I could act in person) to make any and all 4 decisions for me concerning my personal care, medical 5 treatment, hospitalization and health care and to require, 6 withhold or withdraw any type of medical treatment or 7 procedure, even though my death may ensue. My agent shall 8 have the same access to my medical records that I have, 9 including the right to disclose the contents to others. My 10 agent shall also have full power tomake a disposition of any11part or all of my body for medical purposes,authorize an 12 autopsy and direct the disposition of my remains. Effective 13 upon my death, my agent has the full power to make an 14 anatomical gift of the following (initial one): 15 ....Any organ. 16 ....Specific organs:................................ 17 (THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS 18 POSSIBLE SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY 19 DECISION YOU COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF 20 HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD AND WATER AND OTHER 21 LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH ACTION 22 WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU 23 WISH TO LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE 24 SPECIAL RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, 25 AUTHORIZE AUTOPSY OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE 26 FOLLOWING PARAGRAPHS.) 27 2. The powers granted above shall not include the 28 following powers or shall be subject to the following rules 29 or limitations (here you may include any specific limitations 30 you deem appropriate, such as: your own definition of when 31 life-sustaining measures should be withheld; a direction to 32 continue food and fluids or life-sustaining treatment in all 33 events; or instructions to refuse any specific types of 34 treatment that are inconsistent with your religious beliefs HB0404 Enrolled -4- LRB9101374DJcd 1 or unacceptable to you for any other reason, such as blood 2 transfusion, electro-convulsive therapy, amputation, 3 psychosurgery, voluntary admission to a mental institution, 4 etc.): ...................................................... 5 ............................................................. 6 ............................................................. 7 ............................................................. 8 ............................................................. 9 (THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR 10 IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT 11 SUBJECT, SOME GENERAL STATEMENTS CONCERNING THE WITHHOLDING 12 OR REMOVAL OF LIFE-SUSTAINING TREATMENT ARE SET FORTH BELOW. 13 IF YOU AGREE WITH ONE OF THESE STATEMENTS, YOU MAY INITIAL 14 THAT STATEMENT; BUT DO NOT INITIAL MORE THAN ONE): 15 I do not want my life to be prolonged nor do I want 16 life-sustaining treatment to be provided or continued if my 17 agent believes the burdens of the treatment outweigh the 18 expected benefits. I want my agent to consider the relief of 19 suffering, the expense involved and the quality as well as 20 the possible extension of my life in making decisions 21 concerning life-sustaining treatment. 22 Initialed........................... 23 I want my life to be prolonged and I want life-sustaining 24 treatment to be provided or continued unless I am in a coma 25 which my attending physician believes to be irreversible, in 26 accordance with reasonable medical standards at the time of 27 reference. If and when I have suffered irreversible coma, I 28 want life-sustaining treatment to be withheld or 29 discontinued. 30 Initialed........................... 31 I want my life to be prolonged to the greatest extent 32 possible without regard to my condition, the chances I have 33 for recovery or the cost of the procedures. 34 Initialed........................... HB0404 Enrolled -5- LRB9101374DJcd 1 (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN 2 THE MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF 3 ATTORNEY FOR HEALTH CARE LAW" (SEE THE BACK OF THIS FORM). 4 ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS 5 POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS 6 POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND 7 BEYOND IF ANATOMICAL GIFT, AUTOPSY OR DISPOSITION OF REMAINS 8 IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR 9 DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH 10 OF THE FOLLOWING:) 11 3. ( ) This power of attorney shall become effective on 12 ............................................................. 13 ............................................................. 14 (insert a future date or event during your lifetime, such as 15 court determination of your disability, when you want this 16 power to first take effect) 17 4. ( ) This power of attorney shall terminate on ...... 18 ............................................................. 19 (insert a future date or event, such as court determination 20 of your disability, when you want this power to terminate 21 prior to your death) 22 (IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND 23 ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.) 24 5. If any agent named by me shall die, become 25 incompetent, resign, refuse to accept the office of agent or 26 be unavailable, I name the following (each to act alone and 27 successively, in the order named) as successors to such 28 agent: 29 ............................................................. 30 ............................................................. 31 For purposes of this paragraph 5, a person shall be 32 considered to be incompetent if and while the person is a 33 minor or an adjudicated incompetent or disabled person or the 34 person is unable to give prompt and intelligent consideration HB0404 Enrolled -6- LRB9101374DJcd 1 to health care matters, as certified by a licensed physician. 2 (IF YOU WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, 3 IN THE EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, 4 YOU MAY, BUT ARE NOT REQUIRED TO, DO SO BY RETAINING THE 5 FOLLOWING PARAGRAPH. THE COURT WILL APPOINT YOUR AGENT IF 6 THE COURT FINDS THAT SUCH APPOINTMENT WILL SERVE YOUR BEST 7 INTERESTS AND WELFARE. STRIKE OUT PARAGRAPH 6 IF YOU DO NOT 8 WANT YOUR AGENT TO ACT AS GUARDIAN.) 9 6. If a guardian of my person is to be appointed, I 10 nominate the agent acting under this power of attorney as 11 such guardian, to serve without bond or security. 12 7. I am fully informed as to all the contents of this 13 form and understand the full import of this grant of powers 14 to my agent. 15 Signed.............................. 16 (principal) 17 The principal has had an opportunity to read the above 18 form and has signed the form or acknowledged his or her 19 signature or mark on the form in my presence. 20 .......................... Residing at....................... 21 (witness) 22 (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND 23 SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF 24 YOU INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, 25 YOU MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES 26 OF THE AGENTS.) 27 Specimen signatures of I certify that the signatures of my 28 agent (and successors). agent (and successors) are correct. 29 .......................... ................................. 30 (agent) (principal) 31 .......................... ................................. 32 (successor agent) (principal) 33 .......................... ................................. 34 (successor agent) (principal)" HB0404 Enrolled -7- LRB9101374DJcd 1 (b) The statutory short form power of attorney for 2 health care (the "statutory health care power") authorizes 3 the agent to make any and all health care decisions on behalf 4 of the principal which the principal could make if present 5 and under no disability, subject to any limitations on the 6 granted powers that appear on the face of the form, to be 7 exercised in such manner as the agent deems consistent with 8 the intent and desires of the principal. The agent will be 9 under no duty to exercise granted powers or to assume control 10 of or responsibility for the principal's health care; but 11 when granted powers are exercised, the agent will be required 12 to use due care to act for the benefit of the principal in 13 accordance with the terms of the statutory health care power 14 and will be liable for negligent exercise. The agent may 15 act in person or through others reasonably employed by the 16 agent for that purpose but may not delegate authority to make 17 health care decisions. The agent may sign and deliver all 18 instruments, negotiate and enter into all agreements and do 19 all other acts reasonably necessary to implement the exercise 20 of the powers granted to the agent. Without limiting the 21 generality of the foregoing, the statutory health care power 22 shall include the following powers, subject to any 23 limitations appearing on the face of the form: 24 (1) The agent is authorized to give consent to and 25 authorize or refuse, or to withhold or withdraw consent to, 26 any and all types of medical care, treatment or procedures 27 relating to the physical or mental health of the principal, 28 including any medication program, surgical procedures, 29 life-sustaining treatment or provision of food and fluids for 30 the principal. 31 (2) The agent is authorized to admit the principal to or 32 discharge the principal from any and all types of hospitals, 33 institutions, homes, residential or nursing facilities, 34 treatment centers and other health care institutions HB0404 Enrolled -8- LRB9101374DJcd 1 providing personal care or treatment for any type of physical 2 or mental condition. The agent shall have the same right to 3 visit the principal in the hospital or other institution as 4 is granted to a spouse or adult child of the principal, any 5 rule of the institution to the contrary notwithstanding. 6 (3) The agent is authorized to contract for any and all 7 types of health care services and facilities in the name of 8 and on behalf of the principal and to bind the principal to 9 pay for all such services and facilities, and to have and 10 exercise those powers over the principal's property as are 11 authorized under the statutory property power, to the extent 12 the agent deems necessary to pay health care costs; and the 13 agent shall not be personally liable for any services or care 14 contracted for on behalf of the principal. 15 (4) At the principal's expense and subject to reasonable 16 rules of the health care provider to prevent disruption of 17 the principal's health care, the agent shall have the same 18 right the principal has to examine and copy and consent to 19 disclosure of all the principal's medical records that the 20 agent deems relevant to the exercise of the agent's powers, 21 whether the records relate to mental health or any other 22 medical condition and whether they are in the possession of 23 or maintained by any physician, psychiatrist, psychologist, 24 therapist, hospital, nursing home or other health care 25 provider. 26 (5) The agent is authorized: to direct that an autopsy 27 be made pursuant to Section 2 of "An Act in relation to 28 autopsy of dead bodies", approved August 13, 1965, including 29 all amendments; to make a disposition of any part or all of 30 the principal's body pursuant to the Uniform Anatomical Gift 31 Act, as now or hereafter amended; and to direct the 32 disposition of the principal's remains. 33 (Source: P.A. 86-736.)