Illinois Medical Power of Attorney
This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so. It is governed by Illinois law.
Principal Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Phone Number: ___________________
Durability of Power of Attorney:
This Power of Attorney shall remain in effect even if I become disabled or incapacitated.
Grant of Authority:
I hereby grant my agent the authority to make medical decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
Limitations:
My agent's authority is limited as follows:
____________________________________________________________________
____________________________________________________________________
Signatures:
By signing below, I confirm that I understand the contents of this document and that I am signing it voluntarily.
_________________________
Signature of Principal
Date: ____________________
_________________________
Signature of Agent
Date: ____________________
Witnesses:
Two witnesses must sign this document. Witnesses cannot be the agent or related to the principal.
- _________________________
- _________________________
Date: ____________________