IL Statutory Short Form POA for Health free printable template

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. Strike out paragraph 6 if you do not want your agent to act as guardian. ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE hereby revoke all prior powers of attorney for health care executed by me and appoint 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. 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. 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 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. 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. 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 4-5 4-6 and 4-10 c of 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.