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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 benet 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 signicant actions taken

as your agent.

Unless you specically 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 nds 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)

A-1

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.

______ Specic 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.

(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: In Line 3 above, 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 rst take effect.)

(NOTE: If you do not amend or revoke this power, or if you do not specify a specic 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: In Line 4 above, 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 ofce

of agent or be unavailable, I name the following (each to act alone and successively, in the

order named) as successors to such agent:

_____________________________________________________________________________

(insert name and address of successor agent)

_____________________________________________________________________________

(insert name and address of successor 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 certied 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 nds 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)

B-1

B-4

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 identiable health information or

other medical records, including records or communications governed by the Mental Health

and Developmental Disabilities Condentiality 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 dened 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 identiable 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 Condentiality 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 identiable 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 specic limitations you deem appropriate, such as: your

own denition of when life-sustaining measures should be withheld; a direction to continue food

and uids or life-sustaining treatment in all events; or instructions to refuse any specic 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 benets. 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 dened 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 __________

B-2

B-3