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Illinois Statutory Short Form Power Of Attorney For Health Care - Illinois
| Illinois Statutory Short Form Power Of Attorney For Health Care Form. This is a Illinois form and can be used in Miscellaneous Statewide . |
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STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE Includes Amendments Required By Public Act 96-1195 Form Valid July 1, 2011 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. Form Revised September, 2011 755 ILCS 45/4-10 Page 1 of 11 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE, CONTINUED 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 45, 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) Form Revised September, 2011 755 ILCS 45/4-10 Page 2 of 11 American LegalNet, Inc. www.FormsWorkFlow.com ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE 1. I,___________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ (insert name and address of principal, above) 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. Form Revised September, 2011 755 ILCS 45/4-10 Page 3 of 11 American LegalNet, Inc. www.FormsWorkFlow.com 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 a
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