Illinois Medical Power of Attorney Form

The Illinois medical power of attorney form is a legal instrument in which a Principal will name an Agent to oversee their health care decisions with their medical team, to include any end of life decisions. The Principal will not make the document effective until they sign the document. The Principal should read the document carefully prior to signing. If they do not understand the information contained within the document, they should speak with an attorney so that may better understand how the document could affect the Principal and their loved ones if not properly understood and completed.

This document will require the acknowledgement of a Notary Public and a witness. The Principal must understand that they may revoke the document if they so desire.

How to Write

Step 1 – Notice –

  • The Principal must read the entire notice carefully. If the Principal understands the language, they must complete the document accordingly and for their own protection.
  • Initial the Notice page, in the lower right corner of the page before proceeding

Step 2 – Principal’s Information –

  • Enter the full name and address of the Principal
  • If this will revoke a former POA, enter the name and address of the Agent
  • The Principal must read and understand the medical information and “Co-Agent” information
  • Once the paragraph and options are read, go to the next paragraph and initial one of the options. If the Principal fails to initial a selection, it will be assumed that the Agent has no power with regard to organ donation
  • The Principal must continue to review sections C and D

Step 3 – Specific Instructions by the Principal –

  • The Principal may enter any specific instructions they wish to have recognized with regard to any kind of treatment
  • If there could be life threatening treatment, the Principal may wish to add some statements regarding their wishes with regard to these issues to ensure it’s understood by all parties
  • Initial the following lines that are the Principal’s true wishes:
  • “I do not wan my life to be prolonged or life sustaining treatment”
  • “I want my life prolonged and want life sustaining treatments”
  • “I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards without regard to my condition, the chances I have for recovery or the cost of the procedures”

Step 4 – Effective Date –

  • Enter the date in which the Principal would like to allow the document to become effective
  • Enter a termination date

Step 5 – Successor Agent(s) (Optional)

  • In the event the original Agent would pass away or become unwilling or unable to serve, the Principal may name two successor agent’s by entering their names and addresses
  • Read the remaining paragraphs
  • Enter the date of the signature in mm/dd/yyyy
  • Enter the Principal’s signature

Step 6 – Witness Information –

  • Enter the Witnesses Signature
  • Printed name
  • Street Address
  • City, State, Zip Code

Step 7 – Specimen Signatures of Agent’s (Recommended but not required)

  • Enter the signature of the Agent
  • Enter the two Successor Agent’s signatures
  • Principal must sign next to each agent’s signature

Step 8 – Document Preparer’s Information – Enter the information regarding the preparer of this document:

  • Name of Preparer
  • Address
  • Telephone Number