Illinois Health Care Power of Attorney Form

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An Illinois health care power of attorney is a form used to designate another person to handle the medical needs and decision making of another person. The form only becomes effective after the person is no longer able to speak for themselves. In such an event, the agent selected will make health care decisions on their behalf and instruct medical staff to the patient’s wishes. The form is often completed with a living will that outlines the individual’s intent on life-ending treatment options.

Versions (3)


Illinois.gov Health Care Power of Attorney

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Illinois Health Care Power of Attorney – Version 2

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Illinois Health Care Power of Attorney – Version 3

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Laws

Statute755 ILCS 45/Art. IV

Signing Requirements (755 ILCS 45/4-10) – One (1) witness.

How to Write

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Part I. The Principal

(1) Principal Name. This document must be issued by the Private Party who wishes to appoint a specific Health Care Agent with the power to deliver or withhold consent regarding his or her medical treatment when incapacitated. Known as the Principal behind this document, this Private Party must be identified by his or her full name.

(2) Principal Address. The residential address maintained by the Illinois Principal is expected with his or her name.

Part II. The Medical Attorney-in-Fact

(3) Health Care Agent Name. The Illinois Health Care Agent that the Principal wishes to name as the person to make medical decisions when incapacitated must be identified.

(4) Residential Address.

(5) Health Care Agent Phone. 

Part III. The Potential Guardian

(6) Guardian Of Principal’s Person. There may be instances where Illinois Courts will determine it is necessary that a Court-Appointed Guardian be assigned to the Principal. This appointment template can be used to nominate the Health Care Agent for this role (by checking the appropriate statement) or solidify that at the time of this document’s execution the Principal doe not necessarily endorse the Health Care Agent for the role of Court-Appointed Guardian by leaving the checkbox statement unmarked.

Part IV. Activating Medical Powers.

(7) Effect. The authority to represent the Principal’s medical preferences before Illinois Physicians will need an event to trigger the effect of this document (which is to grant such authority to the Health Care Agent named above). The Principal can set this document to become active only when he or she can no longer make health care decisions without giving the Agent any power beforehand, can grant the Agent the power to access and discuss his or her medical records while remaining unable to make the Principal’s health care decisions until the Principal is diagnosed as incapacitated, or, if preferred the Principal can set this document to be in effect as soon as it is signed. Be advised, that the Principal’s decisions will always take precedence. Only one of the effect statements may be initialed by the Principal to apply this definition to the appointment.

Part V. Life-Sustaining Treatments

(8) Quality Of Live Vs Longevity. The Principal can indicate if he or she intends to receive treatment only if his or her quality of life can be maintained or wishes to receive treatment to prolong his or her life regardless of the effect on how the Principal will live afterward. This is an optional area that may be satisfied by selecting one of the two checkboxes that best represent the Principal’s wishes.

Part VI. Specific Limitations

(9) Limitations And Restrictions. The document being completed allows the Health Care Agent to operate to the maximum extent Illinois statutes allow however, this does not mean the Principal must resign himself or herself to this condition. He or she can include limitations on the Health Care Agent’s principal powers or even fully restrict the Agent from certain actions or decisions by declaring such provisions in this appointment. This is left to the discretion of the Principal issuing this paperwork in Illinois.

Part VII. Principal Signature

(10) Signature. The Illinois Principal must sign his or her name to the completed template (ideally) before two Witnesses for this appointment to become effective and valid.

(11) Date. The Principal is also obligated to record the current date immediately upon completing his or her signature.

Part VIII. Witness Testimony

(12) Witness Report. One of two checkboxes must be selected by the Witness validating the Principal’s signature. This will be to report on whether the Witness physically viewed the signing of if the Principal informed the Witness that the signature provided is authentic.

(13) Witness Name. The printed name of the Witness must appear below the statement being made.

(14) Witness Address.

(15) Witness Signature. The Witness should only sign his or her name if the confirmation statement above (including the choice made) is true.

(16) Signature Date. 

Part IX. Successor Agent

(17) Successor Agent #1.  As a precautionary option, the Principal can continue to name two additional Parties. Here, an Agent who can inherit the role of the Illinois Health Care Agent of the Principal should the one named originally in Part I  step down from this role, have his or her powers revoked, or be unable to act on the Principal’s behalf. This Successor Agent will not be able to wield principal power until the Health Care Agent does not fill this role. To set this precaution in motion, the name, address, and phone number of the Successor Agent the Principal wishes for this position.

(18) Successor Agent #2. In addition to Successor Agent #1, the Principal can set up a second Party to take over the Health Care Agent role in Illinois should both the Illinois Health Care Agent and Successor Agent #1 be unable to act in their appointed roles.