Illinois Durable Medical Power of Attorney Form

The Illinois Living Will And Durable Power Of Attorney For Health Care give the Principal the choice of health care they receive if they are no longer able to make these decisions. The document is relevant to persons residing in or from the state of Illinois and is legally binding. This document requires attestation by two (2) witnesses in accordance with 755 ILCS 35/3(b), 755 ILCS 45/4-10.

How to Write

Illinois Short Form Power Of Attorney Form


The principal must initial the notice.

Power Of Attorney For Health Care.

1) The principal must enter their personal details and the personal details of the agent..

  • Principal`s name.
  • Principal`s address.
  • Agent`s name.
  • Agent`s address.


B) Anatomical Gifts

The principal must initial to designate authority and where required denote specific tissues, organs and body parts suitable for donation.

  • Initial to donate any tissues, organs or eyes for transplantation, research or education.
  • Initial to donate specific tissues, organs or body parts for specific purposes.
  • Initial to give the agent authority regarding donation.


Any Other Specific Requirements

2) The principal must enter specific details of any other requirements they would like regarding procedures, treatments and medicines for their end of life healthcare.


Prolonging Of Life

The principal must initial to designate specific conditions regarding prolonging of life.

  • Initial to not prolong life through medical treatment.
  • Initial not to prolong life if the medical professional attending deems the principal permanently unconscious or in an irreversible condition.
  • Initial to prolong life to the greatest extent possible.


Effectiveness Of Power Of Attorney Document

3) The principal must enter the date the Power Of Attorney Document Becomes effective.

4) The principal must enter the date the Power Of Attorney  Document becomes ineffective.


Alternative Agents

5) The principal must enter the personal details of two alternative agents.

  • Agent`s names.
  • Agent`s addresses.



7) The relevant personal details of those mentioned in the document must be entered.

  • Date of completion of the form.
  • Principal`s Signature.
  • Witnesses signature.
  • Printed name of witness.
  • Address of witness.
  • ZIP code of witness.
  • Agent`s and alternative agent`s signatures.
  • Principal`s signature to confirm signatures all of agents.
  • (Optional) Enter personal details of the person preparing the document.