Free Medical Power of Attorney

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Create Your Free Medical Power of Attorney

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  3. Just takes 5 minutes

Medical Power of Attorney

Create Your Medical Power of Attorney


Create Your Medical Power of Attorney

Appoint someone as my agent
Specify my health care preferences
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Your Medical Power of Attorney

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DURABLE POWER OF ATTORNEY FOR HEALTH CARE

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, 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". 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 made this ________ day of ________________, ________

I, _________________________, of ____________________________, ______________________________, Illinois __________, being of sound mind, voluntarily create this Durable Power of Attorney for Health Care.

PRIOR DESIGNATIONS
I revoke any prior Durable Power of Attorney for Health Care.

APPOINTMENT OF HEALTH CARE AGENT
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my agent for health care decisions:

Name: _______________________
Address: _______________________, _______________________, Illinois, __________
Telephone: ______________________________
Relationship: _______________________

AGENT'S AUTHORITY
My agent is authorized to act for me in all matters relating to my health care. My agent's powers include, but are not limited to:

  • Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and the American Recovery and Reinvestment Act of 2009 ("ARRA");
  • Full power to sign any releases in order to obtain this information;
  • Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My agent does not have authority to act for me for any other purpose unrelated to my health care. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE
The designation of my agent will become effective as soon as this document is signed and will remain in effect until my death, or until I revoke it. This designation will not be affected by my subsequent disability or incompetence.

AGENT'S OBLIGATIONS
My agent will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent will make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent will consider my personal values to the extent known to my agent.

NOMINATION OF CONSERVATOR OR GUARDIAN
If a conservator or guardian of my person needs to be appointed for me by a court, I nominate _______________________, the agent designated in this form. My nominated conservator or guardian is not required to post bond or security.

The remainder of this document will be available when you have purchased a license.


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