The new 2016 Illinois Statutory Short Form Power of Attorney for Health Care (“POAHC”) was designed to be “user-friendly” and allow Illinois residents to execute it without the necessity of hiring an attorney. Although I strongly recommend that you meet with an attorney before signing any legal document (including a POAHC), I have provided the basic steps for signing your Power of Attorney for Health Care:

1. Read the “Notice to the Individual Signing the Power of Attorney for Health Care.”
2. Although it is not required, you may place your name and initials at the end of the Notice, to indicate that you read the Notice.
3.  On page 1 of the POAHC, fill in your full name and address.
4. On page 1 of the POAHC, fill in the full name, address and phone number of the person that you choose as your primary health care agent. The Notice contains various considerations when choosing your agent. Your agent must be at least 18 years old, and cannot be a health care professional who is actively involved in your care. See Item 13 below for certain restrictions.Sometimes it can be difficult to pick the right persons to act as your health care agents. The best choices may be your spouse or sibling or adult child or best friend. If you’re having problems choosing agents, please review this Worksheet which contains certain factors to be considered.
   
   Five Traits of the Perfect Health Care Agent
   Health Care Agent Selection Worksheet (pdf document)

   [email-download download_id=”815″ contact_form_id=”801″]

5. In the middle of page one is a box you can check (or initial) if you want the agent under your POAHC to be named as the guardian of your person, if a guardianship proceeding about you is brought. A guardianship proceeding is usually begun if your family members disapprove of the actions of your agent, and want to take control of your medical decisions away from your agent.If you believe that the agents you named will act in your best interests, then checking this box may limit a nuisance lawsuit against your agent.
6. It is a good idea to name successor health care agents, if your first (or second) choice is unavailable or unable to act on your behalf.You should fill in the full name, address and phone number of your successor health care agents near the middle of page 1.
7. At the top of page 2, you should make a choice regarding when your agent is authorized to make medical care decisions for you by initialing (or checking) the appropriate box.Initial the top box if your agent can make decisions only when you cannot make them for yourself. Your agent will not be given any information about your medical condition until you have lost your decision-making ability.

   Initial the middle box if your agent can make decisions only when you cannot make them for yourself, BUT your agent can immediately receive information about your medical condition, so that your agent can assist you with your health care plans.

   Initial the bottom box if you want your agent to immediately have the authority to make decisions for you, unless you later choose to make your own decisions.

8. One important aspect of the POAHC relates to life-sustaining treatments, and how your agent should respond if you aren’t able to express your wishes. At the bottom of page 2, there are two options providing direction to your agent if you are on (or if the doctors suggest putting you on) life-sustaining treatments.It is recommended that you initial the option that most closely reflects your wishes, and that you discuss the nuances of that choice with your agent. If you wish, you can prepare your own statement regarding the application or removal of life-sustaining treatments, nutrition and hydration, and attach it to your POAHC.

   Most people have thought about how they would respond if their death was imminent. However, there seems to be a natural reluctance to discuss death and dying with our loved ones and doctors. For additional information, please see the following:

   How to explain your wishes about life-sustaining treatments

   An exploration of your feelings (blog post)
   READ MORE
   End-of-Life Values Worksheet (pdf document)

   [email-download download_id=”798″ contact_form_id=”801″]

9. Initially, the powers granted to your agent are very broad, and include all decisions that you could make about your care. If you wish, you may set forth specific limitations on your agent’s authority at the top of page 3. Such limitations may include treatments that are inconsistent with your religious or cultural beliefs, or treatments that are otherwise unacceptable to you, such as blood transfusions or amputations.
10. In order to be effective, your POAHC must be signed and dated by you and by an independent witness.
11. First, you must sign and date your Power of Attorney for Health Care near the top of page 3. It is strongly recommended that your witness watch you sign the POAHC.
12. After you have signed and dated the POAHC, your witness must check (or initial) the appropriate box near the middle of page 3.
13. Your witness must not have any relationship to you or your agents, or to your physician or the health care facility. Your witness must review the list of excluded classes of people who cannot act as witness on page 3 of the statutory form. Your witness must confirm that he/she is not prohibited from acting as your witness.
14. If your witness is not prohibited, he/she must fill in his/her name and address, and then sign and date your POAHC on page 3.
15. At the top of page 4 is a place for you to obtain the “specimen signatures” of the agents you appointed in your Power of Attorney. You should also sign across from the specimen signature of each agent to confirm that it represents the appropriate signature. Specimen signatures are primarily for identification purposes. This aspect of the Power of Attorney is not required by statute and does not affect the validity of your Power of Attorney. However, it presents a good opportunity to discuss your wishes with the agents you’ve chosen.
16. Pages 5 and 6 include excerpts from the Illinois Power of Attorney Act, and provide a statement of the purpose and general principles regarding the statutory format.
17. When your health care agent needs to exercise his/her authority under your Power of Attorney, the “Agent’s Certification and Acceptance of Authority” must be completed and signed by your primary agent. This document confirms that the POAHC is valid, and that the agent accepts the role and responsibility of being your health care agent. Do not complete this Certification until it is time for your agent to act on your behalf.
18. If your primary health care agent can’t act on your behalf, then your successor agent must complete and sign the “Successor Agent’s Certification and Acceptance of Authority”. It is similar in function to the “Agent’s Certification” but it also provides an explanation of why the primary health care agent is not available. Do not complete this Certification until it is time for your successor agent to act on your behalf.
19. You may wish to prepare an Addendum to your POAHC which addresses additional matters, such as,
    1. anatomical gifts,
    2. express authority for your agents to receive your personal health information and medical records under HIPAA (important if your POAHC will be used outside of Illinois),
    3. detailed instructions regarding the disposition of your remains and any funeral or memorial services, and
    4. more detailed information regarding your preferences for your medical care and the application or withdrawal of certain life-sustaining treatment, nutrition and/or hydration.

    If you prepare an Addendum, it should be signed by you and your witness using the same procedures as used for the POAHC.

Use the following link to download a copy of these instructions.

Instructions for Signing the 2016 POAHC (pdf document)

Disclaimer:

The 2016 Illinois Statutory Power of Attorney for Health Care form provided by this website closely follows the format set forth in the Illinois Compiled Statutes, Chapter 755, Act 45, Article IV (except where noted). When the form is completed in accordance with these Instructions, it is believed that it will qualify as an Illinois Statutory Short Form Power of Attorney for Health Care. However, such form and Instructions are provided for informational purposes only, and no legal opinion is given as to the effectiveness of such form in any situation. An attorney-client relationship will not be created by use of such form and Instructions. You are urged to consult with your doctor and lawyer before completing and signing the Power of Attorney for Health Care form. Please see the disclaimer for this website for additional details.

Copyright © John M. Varde, P.C., 2016