Illinois Power of Attorney Form for Health Care

ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE

DOCUMENT ID: IL-HCPOA-2024-V1.0
EFFECTIVE DATE: [Effective Date]
VERSION: 1.0
GOVERNING JURISDICTION: State of Illinois, United States

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I. STATUTORY & LEGAL COMPLIANCE NOTICE

NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE:

PLEASE READ THIS NOTICE CAREFULLY. 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 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. You may impose limits on the powers of your agent if you so choose.

This form does not impose a duty on your agent to exercise their powers; however, if the powers are exercised, your agent must use due care for your benefit and in accordance with the terms of this form. 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 you may not name co-agents.

If there is anything about this form that you do not understand, you should ask a lawyer to explain it to you. This document is drafted in accordance with the Illinois Power of Attorney Act (755 ILCS 45/Art. IV).

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II. PARTIES & RECITALS

This Power of Attorney for Health Care is executed on [Effective Date] by and between the following parties:

1. PRINCIPAL:
[Principal Full Legal Name]
[Principal Address]
(hereinafter referred to as the "Principal").

2. HEALTH CARE AGENT:
[Agent Full Legal Name]
[Agent Address]
(hereinafter referred to as the "Agent").

3. SUCCESSOR AGENT(S) (Optional):
If the Agent is unable or unwilling to act, the Principal designates:
[Successor Agent Full Legal Name]
[Successor Agent Address]

RECITALS: The Principal, being of sound mind, intends to create a durable power of attorney for health care in accordance with Illinois law, granting the Agent the authority to make medical decisions on the Principal’s behalf in the event the Principal lacks decisional capacity.

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III. EXHAUSTIVE OPERATIVE CLAUSES

1. Scope of Authority & Engagement

The Principal hereby appoints the Agent as the Principal’s attorney-in-fact (Agent) to make health care decisions for the Principal. This power is effective only when the Principal is unable to make health care decisions, as determined by the Principal’s attending physician. The Agent is authorized to:

• (a) Sign and deliver all medical and health care documents.
• (b) Admit or discharge the Principal from any hospital, hospice, or nursing facility.
• (c) Authorize or refuse any medical procedure, including life-sustaining treatment.
• (d) Access all medical records (as the Principal's "personal representative" under HIPAA).

2. Compensation & Reimbursement

The Agent shall serve without compensation for services rendered. However, the Agent is entitled to reimbursement for all reasonable and necessary expenses (including travel and administrative costs) incurred in the performance of their duties under this instrument, payable from the Principal’s assets within [Number] days of invoice submission.

3. Guidance on Life-Sustaining Treatment

The Principal directs the Agent to follow these specific desires regarding life-sustaining treatment (check/initial only one):

• [ ] CHOICE A: I do not want my life to be prolonged if I have a terminal condition or an irreversible coma/persistent vegetative state.
• [ ] CHOICE B: I want my life to be prolonged to the greatest extent possible, regardless of my condition.
• [ ] CHOICE C: I want my Agent to make the decision based on my best interests and clinical prognosis.

4. Intellectual Property & Confidentiality

All medical information, diagnosis data, and genomic sequences belonging to the Principal are considered "Confidential Information." The Agent is bound by a duty of strict confidentiality and shall not disclose such information to third parties, except as necessary to facilitate medical treatment or legal compliance. No rights to the Principal's biometric or medical data (Intellectual Property) are transferred to the Agent.

5. Representations & Warranties

The Principal represents and warrants that:

• (a) They are of legal age and sound mind.
• (b) They are executing this document voluntarily and without duress.
• (c) This document revokes any prior Health Care Power of Attorney executed by the Principal.

6. Limitation of Liability & Indemnification

The Principal hereby agrees to indemnify and hold the Agent harmless from any and all liability, claims, or damages arising from decisions made in good faith pursuant to this Power of Attorney. The Agent shall not be liable for medical outcomes resulting from the following of the Principal’s stated desires or the advice of medical professionals.

7. Term & Termination

• Term: This Power of Attorney shall remain in effect indefinitely until the death of the Principal or revocation by the Principal.
• Termination for Breach: The Principal may revoke this document at any time, orally or in writing, regardless of the Principal’s mental or physical condition.
• Effect of Death: Upon the death of the Principal, the Agent’s power is limited to anatomical gifts, autopsy authorization, and disposition of remains.

8. Dispute Resolution & Arbitration

Any dispute arising out of or relating to the validity or exercise of power under this document shall be settled by binding arbitration in [County Name], Illinois, in accordance with the rules of the American Arbitration Association. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

9. Governing Law & Jurisdiction

This document shall be governed by, construed, and enforced in accordance with the laws of the State of Illinois, specifically the Illinois Power of Attorney Act.

10. Miscellaneous Provisions

• Severability: If any provision is held invalid, the remainder shall remain in full force.
• Counterparts: This document may be executed in counterparts, including electronic copies, which together constitute one instrument.
• Entire Agreement: This document constitutes the entire agreement regarding health care agency.

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IV. EXECUTION & FORMAL SIGNATURE BLOCKS

FOR THE PRINCIPAL: I, [Principal Full Legal Name], the principal, sign my name to this power of attorney this [Day] day of [Month], [Year].

Signature: _____________________________________
Printed Name: [Principal Full Legal Name]
Address: [Principal Address]
Date: [Date]

FOR THE WITNESS: I certify that the Principal is personally known to me, signed this document in my presence, and appears to be of sound mind and under no duress. I am not the Agent, a health care provider, or a relative of the Principal.

Signature: _____________________________________
Printed Name: [Witness Full Legal Name]
Address: [Witness Address]
Date: [Date]

NOTARY ACKNOWLEDGMENT (REQUIRED FOR INSTITUTIONAL VALIDITY): STATE OF ILLINOIS ) COUNTY OF [County Name] )

On this [Day] day of [Month], [Year], before me personally appeared [Principal Full Legal Name], to me known to be the person described in and who executed the foregoing instrument, and acknowledged that they executed the same as their free act and deed.

Signature: _____________________________________
(Seal) My Commission Expires: [Expiration Date]

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V. STEP-BY-STEP EXECUTION & FILING GUIDE

1. Field Completion: Open this document in Microsoft Word or Google Docs. Replace all bracketed text (e.g., [Principal Full Legal Name]) with the accurate, legal names and addresses.
2. Selection of Agent: Ensure the Agent is over 18 and not your direct health care provider.
3. Witnessing: You MUST sign in the presence of at least one witness. The witness cannot be your agent, your attending physician, or certain other medical staff.
4. Notarization: While Illinois law has specific witness requirements, having the document notarized ensures "Institutional-Grade" acceptance at hospitals and banks across state lines.
5. Digital Signature (Optional): If using DocuSign/Adobe Sign, ensure the platform provides a "Certificate of Completion" and meets Illinois Electronic Signature Act requirements. However, many hospitals still prefer "wet ink" signatures for medical powers of attorney.
6. Distribution:
   • Provide a copy to your designated Agent.
   • Provide a copy to your Primary Care Physician (PCP).
   • Keep the original in a secure, accessible location (not a safe deposit box).
7. Retention: This document should be reviewed annually. If you move out of Illinois, you should execute a new form specific to that state's statutes.