ILLINOIS HEALTH CARE POWER OF ATTORNEY
(Comprehensive Attorney Draft – 755 ILCS 45/4-1 et seq.)

[// GUIDANCE: This template is intentionally more robust than the statutory “Short Form.”
It tracks the Illinois Power of Attorney Act while layering in defensive drafting, HIPAA compliance, and optional end-of-life directives. Delete or tailor any bracketed language to meet your client’s wishes.]

TABLE OF CONTENTS

1. Section I Document Header & Recitals
2. Section II Definitions
3. Section III Operative Provisions
4. Section IV Representations & Warranties
5. Section V Covenants & Restrictions
6. Section VI Default & Remedies
7. Section VII Risk Allocation
8. Section VIII Dispute Resolution
9. Section IX General Provisions
10. Section X Execution Block
11. Attachment A Notice to the Individual Signing This Power of Attorney
12. Attachment B Notice to Health Care Agent
13. Attachment C HIPAA Authorization

SECTION I

DOCUMENT HEADER & RECITALS
1. Title. This Health Care Power of Attorney (“Power of Attorney” or “POA”) is executed pursuant to the Illinois Power of Attorney Act, 755 ILCS 45/4-1 et seq. (the “Act”).
2. Parties.
a. Principal: [PRINCIPAL LEGAL NAME], residing at [ADDRESS] (“Principal”).
b. Primary Health Care Agent: [AGENT LEGAL NAME], residing at [ADDRESS] (“Agent”).
c. First Successor Agent (optional): [SUCCESSOR 1], residing at [ADDRESS].
d. Second Successor Agent (optional): [SUCCESSOR 2], residing at [ADDRESS].
3. Effective Date. This POA becomes effective (check one):
☐ Upon the Principal’s signing.
☐ Only upon a written determination of incapacity by [ONE/TWO] licensed physicians.
4. Consideration & Intent. Principal executes this POA in consideration of Agent’s agreement to act and with the intent that Agent’s authority be honored by all third parties in accordance with the Act.
5. Governing Law. This POA and all rights hereunder are governed by Illinois substantive law applicable to health-care decisions.

SECTION II

DEFINITIONS
For ease of reference, capitalized terms are defined alphabetically below.

“Act” – The Illinois Power of Attorney Act, 755 ILCS 45, Article IV.

“Advance Directive” – Written instructions about health care, including this POA, any Living Will, POLST, or DNR order.

“Agent” – The Primary Agent or, if the Primary Agent is unable or unwilling to act, the first then available Successor Agent.

“Good Faith” – Honesty in fact and the reasonable belief that the action is lawful and consistent with the Principal’s known wishes or best interests.

“Health Care” – Any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect the Principal’s physical or mental condition.

“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its privacy regulations (45 C.F.R. Parts 160 & 164).

“Incapacity” – A determination, in writing, by a licensed physician that Principal lacks capacity to make or communicate health-care decisions.

“Principal” – The individual granting authority herein.

“Protected Health Information” or “PHI” – Health information protected under HIPAA.

“Successor Agent” – An individual named to act if the Primary Agent is unavailable, in order of listing above.

SECTION III

OPERATIVE PROVISIONS

3.1 Appointment of Agent. Principal hereby appoints Agent as lawful attorney-in-fact for Health Care matters, with full power to act as permitted under the Act and this POA.

3.2 Scope of Authority. Subject to Section 3.3 and any limitations stated in Section 5.2, Agent may:
a. Consent, refuse, or withdraw consent to any Health Care;
b. Access and disclose PHI as authorized in Attachment C;
c. Employ and discharge health-care providers;
d. Make anatomical gifts, authorize autopsy, and dispose of remains consistent with Section 3.4;
e. Apply for public benefits and insurance for medical expenses;
f. Execute any required documents, waivers, or releases.

3.3 End-of-Life Directives. If Principal has an incurable and irreversible condition expected to result in death within a relatively short time, or if Principal is permanently unconscious:
a. Life-Prolonging Treatment. Principal’s preference is (select one):
☐ WITHHOLD or withdraw life-prolonging treatment.
☐ PROVIDE life-prolonging treatment.
☐ Agent to decide after consultation with medical providers.
b. Artificial Nutrition/Hydration. Principal’s preference is (select one):
☐ WITHHOLD or withdraw artificial nutrition/hydration.
☐ PROVIDE artificial nutrition/hydration.
☐ Agent to decide.
c. Palliative Care. Comfort care shall always be provided, even if it may hasten death.

3.4 Anatomical Gifts & Disposition of Remains. (Check all that apply)
☐ Donate any organs/tissues.
☐ Donate only the following: [SPECIFY].
☐ No donation.
☐ Cremation preferred.
☐ Burial preferred at [CEMETERY].

3.5 Guardian Nomination. Pursuant to 755 ILCS 5/11a-6, Principal nominates Agent to serve as guardian of the person if guardianship becomes necessary.

3.6 Reliance by Third Parties. Any person may rely upon the Agent’s representation of authority without liability so long as the person acts in Good Faith and observes Section 6.3.

SECTION IV

REPRESENTATIONS & WARRANTIES

4.1 Principal’s Representations. Principal represents that:
a. Principal is at least 18 years old, of sound mind, and acting voluntarily.
b. No court has appointed a guardian for Principal’s person.
c. Principal has reviewed the statutory “Notice to the Individual” attached hereto as Attachment A.

4.2 Agent’s Representations. By executing the Acceptance in Section 10.4, Agent represents that Agent:
a. Is at least 18 years old and not disqualified under the Act;
b. Accepts fiduciary duties under the Act and this POA;
c. Has reviewed Attachment B (Notice to Agent).

4.3 Survival. All representations and warranties survive revocation as to actions taken prior thereto.

SECTION V

COVENANTS & RESTRICTIONS

5.1 Agent’s Fiduciary Duties. Agent shall:
a. Act in Good Faith and in accordance with Principal’s known wishes;
b. Consult appropriate professionals as needed;
c. Keep records of significant decisions.

5.2 Agent Authority Limitations. Agent’s authority is expressly limited as follows: [INSERT ANY LIMITATIONS OR “NONE.”]

5.3 Notice of Incapacity Determination. Upon learning of a written determination of Principal’s capacity or recovery, Agent shall promptly notify relevant health-care providers.

SECTION VI

DEFAULT & REMEDIES

6.1 Events of Default. It is a default if:
a. Agent acts outside the scope of authority;
b. Agent breaches fiduciary duties;
c. Agent becomes incapacitated or resigns without notice.

6.2 Cure Period. A Successor Agent or interested person may give written notice to the Primary Agent specifying the alleged breach. The Primary Agent shall have [5] days to cure, unless irreparable harm would result.

6.3 Remedies. In addition to any statutory remedy, the following apply:
a. Injunctive Relief. Interested persons may seek injunctive relief in the probate division of the Circuit Court to enforce or suspend Agent powers.
b. Attorneys’ Fees. A prevailing party in any action to enforce this POA may recover reasonable attorneys’ fees and costs.

SECTION VII

RISK ALLOCATION

7.1 Indemnification. Principal shall indemnify and hold harmless Agent from any liability, loss, or expense (including attorneys’ fees) incurred by reason of acting under this POA, provided the Agent acted in Good Faith.

7.2 Limitation of Liability. Neither Agent nor any third party relying on this POA in Good Faith shall be liable for actions taken consistent with its terms and the Act.

7.3 Insurance. Agent is authorized, but not obligated, to obtain liability insurance or surety bonds, payable from the Principal’s assets, to protect against claims arising from acts undertaken in Good Faith.

7.4 Force Majeure. Agent shall not be liable for failure to act when prevented by circumstances beyond Agent’s reasonable control.

SECTION VIII

DISPUTE RESOLUTION

8.1 Governing Law. This POA shall be construed in accordance with the laws of the State of Illinois, without regard to conflict-of-laws principles.

8.2 Forum Selection. The probate division of the Circuit Court of the county in which the Principal resides (or is receiving care) shall have exclusive jurisdiction over any proceeding arising under this POA.

8.3 Arbitration & Jury Trial. Arbitration and jury trial waivers are intentionally omitted; disputes shall be resolved by the court referenced in Section 8.2.

8.4 Injunctive Relief. Nothing herein limits the court’s power to grant emergency or injunctive relief necessary to carry out the Principal’s health-care directives.

SECTION IX

GENERAL PROVISIONS

9.1 Amendment & Revocation. Principal may amend or revoke this POA in writing at any time, consistent with 755 ILCS 45/4-7, by delivering notice to Agent and, where practicable, Principal’s primary physician.

9.2 Copies. Photocopies, facsimiles, and electronically transmitted counterparts of this POA shall have the same force as an original.

9.3 Severability. If any provision of this POA is invalid, the remaining provisions shall remain in full force.

9.4 Integration. This POA, together with all Attachments, constitutes the entire agreement concerning the subject matter and supersedes all prior oral or written directives, except any Living Will or POLST that is not expressly revoked.

9.5 Assignment. Agent’s authority is personal and non-delegable except as expressly permitted by the Act.

9.6 Headings. Headings are for convenience only and do not affect interpretation.

9.7 Digital Execution. To the extent permitted by law, this POA may be executed and stored electronically.

SECTION X

EXECUTION BLOCK

10.1 Principal’s Signature.

____ __
[PRINCIPAL LEGAL NAME] Date

10.2 Witness Attestation.
[// GUIDANCE: One adult witness is required; statutory disqualifications apply under 755 ILCS 45/4-5(c).]

I, the undersigned witness, certify that on the date written below (a) I am at least 18 years old, (b) I witnessed the Principal sign or acknowledge this POA, (c) the Principal appears to be of sound mind and under no duress, fraud, or undue influence, and (d) I am not disqualified under the Act.

____ __
Witness Signature Date
Printed Name: ______
Address: _________

10.3 Optional Notarization. (Not required but recommended for out-of-state recognition.)

State of Illinois )
) SS.
County of _____)

On ____, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL], personally known to me (or proved to me on the basis of satisfactory evidence) to be the individual whose name is subscribed to this instrument, and acknowledged that he/she executed it.

Notary Public

My Commission Expires: ____

10.4 Agent’s Acceptance & Acknowledgment.
I accept the appointment as Agent and acknowledge my fiduciary duties under this POA and the Act.

____ __
[AGENT LEGAL NAME] Date

(Successor Agents sign below only if and when they assume authority.)

ATTACHMENT A

NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS POWER OF ATTORNEY FOR HEALTH CARE
[// GUIDANCE: Insert verbatim statutory notice language from 755 ILCS 45/4-10 here.]

ATTACHMENT B

NOTICE TO HEALTH CARE AGENT
[// GUIDANCE: Insert verbatim statutory notice language from 755 ILCS 45/4-10 here.]

ATTACHMENT C

HIPAA AUTHORIZATION

1. Authorization. Pursuant to 45 C.F.R. §164.508(c), Principal authorizes any Covered Entity to disclose PHI to Agent.
2. Purpose. For health-care decision-making, payment, and insurance purposes.
3. Scope. This authorization applies to all medical records, including mental health and substance-abuse treatment records, unless limited here: [LIMITATIONS OR “NONE.”]
4. Expiration. This authorization is effective immediately and shall remain in effect until the earliest of (a) Principal’s written revocation, (b) complete revocation of this POA, or (c) [TEN (10)] years after Principal’s death.
5. Redisclosure. Information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA.
6. Signature.

____ __
[PRINCIPAL] Date

[// GUIDANCE: After execution, provide copies to the Agent, Successor Agents, primary physician, and relevant health-care facilities. Consider scanning and uploading to the Illinois POLST or electronic medical record systems for immediate availability.]