Medical Power of Attorney Form for Illinois

ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE

INSTITUTIONAL-GRADE LEGAL INSTRUMENT

Document ID: IL-HCPOA-2024-001
Effective Date: [Effective Date]
Governing Jurisdiction: State of Illinois
Statutory Authority: 755 ILCS 45/4-1 (Illinois Power of Attorney Act)

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1. 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 form that you are about to sign is a legal document. It gives the person you designate as your agent the broad power 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 state in this form any specific limitations or types of treatment that you do not want to receive or have those that you do want to receive. This form does not impose a duty on your agent to exercise their powers; but, when powers are exercised, your agent must use due care to act for your benefit and in accordance with this form.

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2. PARTIES AND RECITALS

This Medical Power of Attorney (“Agreement”) is executed by and between:

PRINCIPAL: [Full Legal Name of Principal]
[Principal Physical Address]
[Principal Social Security Number (Optional/Last 4)]

AGENT (Attorney-in-Fact): [Full Legal Name of Primary Agent]
[Agent Physical Address]
[Agent Telephone Number]

SUCCESSOR AGENT(S) (Optional): If the Agent above is unable or unwilling to serve, I appoint: [Full Legal Name of Successor Agent]
[Successor Agent Physical Address]
[Successor Agent Telephone Number]

RECITALS: I, the Principal, being of sound mind and acting of my own free will, intend to create a durable power of attorney for health care in accordance with the Illinois Power of Attorney Act. This document shall supersede any prior health care directives or powers of attorney executed by me.

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3. EXHAUSTIVE OPERATIVE CLAUSES & LEGAL TERMS

3.1 Scope of Authority (Engagement)

The Principal hereby engages the Agent to act as the Principal’s representative for all health care decisions. This scope includes, but is not limited to:

• (a) Access to any and all medical records, including psychiatric and HIV status records.
• (b) Selection and discharge of medical providers and institutions.
• (c) Consent to or refusal of any medication, surgery, or therapeutic procedure.
• (d) Decisions regarding life-sustaining treatments (ventilators, clinical nutrition, hydration).

3.2 Compensation & Payment Terms

The Agent shall serve without specific hourly compensation for their time. However, the Agent is entitled to immediate reimbursement from the Principal’s assets for all reasonable and necessary expenses incurred in the performance of their duties under this Agreement. No prior court approval is required for such reimbursement.

3.3 Term & Termination (Revocation)

(a) Commencement: This Power of Attorney becomes effective immediately upon execution unless otherwise specified herein. (b) Duration: This is a DURABLE power of attorney and shall not be affected by the subsequent disability or incapacity of the Principal. (c) Termination: This Agreement terminates upon the death of the Principal, except for powers regarding anatomical gifts or autopsy. The Principal may revoke this Power of Attorney at any time by oral, written, or other expression of intent to revoke, regardless of mental or physical capacity.

3.4 Confidentiality, HIPAA & Work Product

The Agent is hereby designated as the Principal's "Personal Representative" as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164. The Agent has the same right as the Principal to examine, question, and copy medical records and to consent to the disclosure of such records to third parties.

3.5 Representations & Warranties

The Principal warrants that they are of legal age (18 or older) and are not under duress or undue influence. The Agent, by accepting this appointment, warrants that they are not a health care provider or an operator of a health care facility where the Principal is receiving care, unless related to the Principal as defined by Illinois law.

3.6 Limitation of Liability & Indemnification

(a) Agent Liability: The Agent shall not be liable for any error in judgment or for any act or omission done in good faith, provided such act does not constitute willful misconduct or gross negligence. (b) Indemnification: The Principal’s estate shall indemnify and hold the Agent harmless from any liability, costs, or damages arising from the Agent’s exercise of powers granted under this Agreement.

3.7 Dispute Resolution & Arbitration

Any dispute regarding the validity or interpretation of this Agreement that cannot be resolved through the Illinois Probate Court system shall be submitted to binding arbitration in [County], Illinois, in accordance with the rules of the American Arbitration Association.

3.8 Miscellaneous Provisions

(a) Severability: If any provision of this document is held invalid, such invalidity shall not affect other provisions that can be given effect without the invalid provision. (b) Governing Law: This document is governed by the laws of the State of Illinois. (c) Counterparts: This document may be executed in counterparts, each of which shall be deemed an original.

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4. PRINCIPAL DIRECTIVES (LIFE-SUSTAINING TREATMENT)

Initial only one of the following statements:

[____] (A) Choice Not to Prolong Life: 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.

[____] (B) Choice to Prolong Life: I want my life to be prolonged and I want life-sustaining treatment to be provided or continued unless this treatment is certain to result in immediate death.

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5. EXECUTION & FORMAL SIGNATURE BLOCKS

FOR THE PRINCIPAL: Signature: _____________________________________ Printed Name: [Full Legal Name of Principal] Date: [Date of Signing] Address: [Principal Address]

FOR THE AGENT (ACCEPTANCE OF APPOINTMENT): I, [Agent Full Name], accept the appointment as Agent and understand my duties. Signature: _____________________________________ Printed Name: [Full Legal Name of Agent] Date: [Date of Signing]

WITNESS ATTESTATION: I certify that the Principal is personally known to me, signed this document in my presence, and appears to be of sound mind and not under duress. I am not the Agent, a health care provider, or an employee of a health care facility. Signature: _____________________________________ Printed Name: [Witness Full Name] Address: [Witness Address] Date: [Date of Signing]

NOTARY ACKNOWLEDGMENT (REQUIRED FOR INSTITUTIONAL PORTABILITY): STATE OF ILLINOIS COUNTY OF [COUNTY NAME] On this [Day] of [Month], 20[Year], before me personally appeared [Principal Name], known to me to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. Notary Public Signature: _____________________________________ (Seal)

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6. STEP-BY-STEP EXECUTION & FILING GUIDE

1. Preparation of Document: Replace all bracketed text [...] with the specific legal names, addresses, and dates. Ensure the "Life-Sustaining Treatment" section (Section 4) is initialed.
2. Verify Signatory Capacity: Ensure the Principal is conscious and capable of understanding the document at the time of signing.
3. Witnessing Requirements: In Illinois, you must have at least one witness. The witness cannot be the agent, your doctor, or an owner of the facility where you are being treated.
4. Notarization: While Illinois law for Health Care POA is valid with a witness, most hospitals and out-of-state institutions require a Notary Public's seal for verification. This form includes a Notary block for maximum enforceability.
5. Digital Signature Execution: If using DocuSign or Adobe Sign, ensure the platform generates a "Certificate of Completion" that captures the IP address and timestamp of the electronic signature. Note that some medical facilities still prefer "wet ink" signatures.
6. Distribution & Retention:
   • Original: Keep in a secure, accessible location (not a safe deposit box).
   • Copies: Provide copies to the Primary Agent, Successor Agent, and your Primary Care Physician (PCP).
   • Institutional Filing: Ensure a copy is uploaded to your Electronic Health Record (EHR) at your preferred hospital system (e.g., Northwestern, Rush, UChicago).
7. Periodic Review: Review this document every 2–3 years or after any major life event (marriage, divorce, or diagnosis).