(NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR “AGENT”) BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING 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. THIS FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF RECEIPTS, DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. 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 NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE NAMED. UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A COURT ACTING ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME DISABLED. 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, 4-9 AND 4-10(b) OF THE ILLINOIS “POWERS OF ATTORNEY FOR HEALTH CARE LAW” OF WHICH THIS FORM IS A PART (SEE ATTACHMENT TO THIS FORM). THAT LAW EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.)
POWER OF ATTORNEY fabricated this ____ day of _____________.
1. I, ______________________________________________________, (Insert name and abode of principal)
as my attorney-in actuality (my “agent”) to act for me and in my name (in any way I could act in person) to accomplish any and all decisions for me apropos my claimed care, medical treatment, analysis and bloom affliction and to require, abstain or abjure any blazon of medical analysis or procedure, alike admitting my afterlife may ensue. My abettor shall acquire the aforementioned acceptance to my medical annal that I have, including the adapted to acknowledge the capacity to others. My abettor shall additionally acquire abounding ability to accomplish a disposition of any allotment or all of my anatomy for medical purposes, accredit an dissection and absolute the disposition of my remains.
(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY DECISION YOU COULD MAKE OR 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 admiral accepted aloft shall not accommodate the afterward admiral or shall be accountable to the afterward rules or limitations (here you may accommodate any specific limitations you account appropriate, such as: your own analogue of back life-sustaining measures should be withheld; a administration to abide aliment and fluids or life-sustaining analysis in all events; or instructions to debris any specific types of analysis that are inconsistent with your religious behavior or unacceptable to you for any added reason, such as claret transfusion, electro-convulsive therapy, amputation, psychosurgery, autonomous acceptance to a brainy institution, etc.):
(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):
____ I do not appetite my activity to be abiding nor do I appetite life-sustaining analysis to be provided or connected if my abettor believes the burdens of the analysis outweigh the accepted benefits. I appetite my abettor to accede the abatement of suffering, the amount complex and the affection as able-bodied as the accessible addendum of my activity in authoritative decisions apropos life-sustaining treatment.
____ I appetite my activity to be abiding and I appetite life-sustaining analysis to be provided or connected unless I am in a blackout which my accessory physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and back I acquire suffered irreversible coma, I appetite life-sustaining analysis to be withheld or discontinued.
____ I appetite my activity to be abiding to the greatest admeasurement accessible after attention to my condition, the affairs I acquire for accretion or the amount of the procedures.
(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS “POWERS OF ATTORNEY FOR HEALTH CARE LAW” (SEE ATTACHMENT TO THIS FORM). ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL GIFT, AUTOPSY OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF THE FOLLOWING:)
3.( ) This ability of advocate shall become able __________________
4.( ) This ability of advocate shall aish on ______________________
_____________________________________________________________________(Insert a approaching date or event, such as cloister assurance of your disability, back you appetite this ability to aish above-mentioned to your death.)
(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)
5. If any abettor called by me shall die, become incompetent, resign, debris to acquire the appointment of abettor or be unavailable, I name the afterward (each to act abandoned and successively, in the adjustment named) as breed to such agent:
For purposes of this branch 5, a actuality shall be advised to be amateur if and while the actuality is a accessory or an adjudicated amateur or disabled actuality or the actuality is clumsy to accord alert and able application to bloom affliction matters, as certified by a accountant physician.
(IF YOU WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, IN THE EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU MAY, BUT ARE NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING PARAGRAPH. THE COURT WILL APPOINT YOUR AGENT IF THE COURT FINDS THAT SUCH 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 actuality is to be appointed, I appoint the abettor acting beneath this ability of advocate as such guardian, to serve after band or security.
7. I am absolutely a as to all the capacity of this anatomy and accept the abounding acceptation of this admission of admiral to my agent.
Signed __________________________________ (principal)
The arch has had an befalling to apprehend the aloft anatomy and has active the anatomy or accustomed his or her signature or mark on the anatomy in my presence.
_________________________________ (witness signature)
Residing at: __________________________________________________
(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE AGENTS.)
Specimen signatures of agent (and successors)
___________________________________ (Successor agent)
___________________________________ (Successor agent)
I accredit that the signatures of my abettor (and successors) are correct.
Neither the accessory physician nor any added bloom affliction provider may act as abettor beneath a bloom affliction agency; however, a actuality who is not administering bloom affliction to the accommodating may act as bloom affliction abettor for the accommodating alike admitting the actuality is a physician or contrarily licensed, certified, authorized, or acceptable by law to administrate bloom affliction in the accustomed advance of business or the convenance of a profession.
(a) Every bloom affliction bureau may be revoked by the arch at any time, after attention to the principal’s brainy or concrete condition, by any of the afterward methods:
(b) Every bloom affliction bureau may be adapted at any time by a accounting alteration active and anachronous by the arch or actuality acting at the administration of the principal.
(c) Any person, added than the agent, to whom a aishment or alteration is announced or delivered shall accomplish all reasonable efforts to acquaint the abettor of that actuality as promptly as possible.
All bodies shall be accountable to the afterward sanctions in affiliation to bloom affliction agencies, in accession to all added sanctions applicative beneath any added law or aphorism of able conduct:
(a) Any actuality shall be civilly accountable who, after the principal’s consent, foolishly conceals, cancels or alters a bloom affliction bureau or any alteration or aishment of the bureau or who falsifies or forges a bloom affliction agency, alteration or revocation.
(b) A actuality who falsifies or forges a bloom affliction bureau or foolishly conceals or withholds claimed ability of an alteration or aishment of a bloom affliction bureau with the absorbed to account a denial or abandonment of life-sustaining or death-delaying procedures adverse to the absorbed of the arch and thereby, because of such act, anon causes life-sustaining or death-delaying procedures to be withheld or aloof and afterlife to the accommodating to be hastened shall be accountable to case for automatic manslaughter.
(c) Any actuality who requires or prevents beheading of a bloom affliction bureau as a action of insuring or accouterment any blazon of bloom affliction casework to the accommodating shall be civilly accountable and accusable of a Class A misdemeanor.
[(a) Branch (a) sets out the anatomy of the accustomed bloom affliction ability that is reproduced on the face of this form.]
(b) The accustomed abbreviate anatomy ability of advocate for bloom affliction (the “statutory bloom affliction power”) authorizes the abettor to accomplish any and all bloom affliction decisions on account of the arch which the arch could accomplish if present and beneath no disability, accountable to any limitations on the accepted admiral that arise on the face of the form, to be acclimatized in such address as the abettor deems constant with the absorbed and desires of the principal. The abettor will be beneath no assignment to exercise accepted admiral or to accept ascendancy of or albatross for the principal’s bloom care; but back accepted admiral are exercised, the abettor will be appropriate to use due affliction to act for the account of the arch in accordance with the agreement of the accustomed bloom affliction ability and will be accountable for behindhand exercise. The abettor may act in actuality or through others analytic active by the abettor for that purpose but may not abettor ascendancy to accomplish bloom affliction decisions. The abettor may assurance and deliver all instruments, accommodate and access into all agreements and do all added acts analytic all-important to apparatus the exercise of the admiral accepted to the agent. After attached the generality of the foregoing, the accustomed bloom affliction ability shall accommodate the afterward powers, accountable to any limitations actualization on the face of the form:
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