Draft Statutory of Power of Attorney for Health Care and Probate Rider

Dear Readers;

As many of you are aware, there are tremendous problems in Probate Court, Cook County, Illinois, regarding many issues that make life extremely difficult for the disabled.

While this document most likely won’t even solve a portion of those problems, at least it 1) makes people aware these are severe problems, 2) perhaps the Illinois Legislature can give its grace to some of these clauses and provisions and 3) we need to figure out a way to solve the current crisis where people are declared incompetent, they want an atty but are not brave or strong enough to tell that to their abuser–esp. when the abuser is the Guardian and/or the GAL, and we need to warn people up front to make an inventory of valuable personal items and give it to your insurance company and attorney.

Use the Reply section if you can think of anything else.

I’ll post this from time to time to see if there are improvements.

AS ALWAYS, HAVE AN ATTY REVIEW ALL DOCUMENTS YOU SIGN!

thanks

JoAnne

POWER OF ATTORNEY FOR HEALTH CARE

ILLINOIS STATUTORY SHORT FORM 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 IN
THE MANNER PROVIDED BELOW, 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” OF WHICH THIS FORM IS A PART (SEE THE
BACK OF THIS FORM). THAT LAW EXPRESSLY PERMITS THE USE OF ANY
DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY DESIRE. IF THERE IS
ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD
ASK A LAWYER TO EXPLAIN IT TO YOU.)

THIS POWER OF ATTORNEY has been made and signed on

this ___ day of ________________ 20___

I hereby appoint:  (insert name and address of principal)

name: _____________________________________

address:_________________________________________________________________
(insert name and address of agent)

as my attorney-in-fact (my “agent”) to act for me and in my name (in any way I could act in
person) to make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, even though my death may ensue. My agent shall have the same access to my medical records that I have, including the right to disclose the contents to others. My agent shall also have full power to authorize an autopsy and direct the disposition of my remains. Effective upon my death, my agent has the full power to make an anatomical gift of the
following (initial one):
_________ (initials) Any organ OR
_________ (initials) Specific organs: _________________________________________

(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS POSSIBLE SO
THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY DECISION YOU
COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF HEALTH CARE,
INCLUDING WITHDRAWAL OF FOOD AND WATER AND OTHER LIFE-SUSTAINING
MEASURES, IF YOUR AGENT BELIEVES SUCH ACTION WOULD BE CONSISTENT
WITH YOUR INTENT AND DESIRES. IF YOU WISH TO LIMIT THE SCOPE OF YOUR
AGENT’S POWERS OR PRESCRIBE SPECIAL RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE AUTOPSY OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE FOLLOWING PARAGRAPHS.)

2.The powers granted above shall not include the following powers or shall be subject to the following rules or limitations (here you may include any specific limitations you deem
appropriate, such as: your own definition of when life-sustaining measures should be withheld; a direction to continue food and fluids or life-sustaining treatment in all events; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason, such as blood transfusion, electro-convulsive therapy, amputation, psychosurgery, voluntary admission to a mental institution, etc.):

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

(THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR
IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, SOME
GENERAL STATEMENTS CONCERNING THE WITHHOLDING OR REMOVAL OF LIFESUSTAINING    TREATMENT ARE SET FORTH BELOW. IF YOU AGREE WITH ONE OFTHESE STATEMENTS, YOU MAY INITIAL THAT STATEMENT; BUT DO NOT INITIAL
MORE THAN ONE):

_______(initial, if desired) I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining treatment, OR:

_______(initial, if desired) I want my life to be prolonged and I want life-sustaining treatment to be provided or continued unless I am in a coma which my attending physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered irreversible coma, I want life-sustaining treatment to be withheld or discontinued, OR:

_______(initial, if desired) I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures.

(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE
MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS “POWERS OF ATTORNEY
FOR HEALTH CARE LAW” (SEE THE BACK OF THIS FORM). ABSENT AMENDMENT
OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY
WILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED AND WILL
CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE
BEGINNING DATE OR DURATION IS MADE BY INITIALING AND COMPLETING
EITHER OR BOTH OF THE FOLLOWING:)

3.(______) This power of attorney shall become effective on
_____________________________________________________________________

(insert a future date or event during your lifetime, such as court determination of your
disability, when you want this power to first take effect)
4.(_____ ) This power of attorney shall terminate on

____________________________________________________________________.
(insert a future date or event, such as court determination of your disability, when you want this power to terminate prior to your death)

(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND
ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)

5.If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be unavailable, I name the following (each to act alone and successively, in the order named) as successors to such agent:

_________________________________________________________(name & address)

_________________________________________________________(name & address)

For purposes of this paragraph 5, a person shall be considered to be incompetent if and while the person is a minor or an adjudicated incompetent or disabled person or the person is unable to give prompt and intelligent consideration to health care matters, as certified by a licensed physician. (IF YOU WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, IN THE EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU MAY, BUT ARE NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING
PARAGRAPH. THE COURT WILL APPOINT YOUR AGENT IF THE COURT FINDS
THAT SUCH APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND WELFARE.
STRIKE OUT PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT TO ACT AS
GUARDIAN.)

6.If a guardian of my person is to be appointed, I nominate the agent acting under this power of attorney as such guardian, to serve without bond or security.

7.I am fully informed as to all the contents of this form and understand the full import of this
grant of powers to my agent.

8.  I have adopted the attached Probate Health Care Rider with specific instructions to the Probate Court should I be ajudicated “disabled” in any Probate Court where I am located.

Signed______________________________________
(principal)

The principal has had an opportunity to read the above form and has signed the form or
acknowledged his or her signature or mark on the form in my presence.
.Signed: __________________________________________(witness)

Name of witness printed ______________________________________

Address of witness __________________________________________

(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND
SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU
INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST
COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE AGENTS.)
Specimen signatures of agent (and I certify that the signatures of my
successors). agent (and successors) are correct.

____________________________________________
(agent) (principal)

____________________________________________
(successor agent) (principal)

____________________________________________
(successor agent) (principal)

PROBATE COURT RIDER

Dated this _____ day of __________________ 20___

I hereby declare that I do not agree with all aspects of how the Probate Courts function in most states, and in particular the Illinois Probate Court.

I therefore am leaving specific instructions to my Power of Attorney (POA) Agent for Health Care appointed in the foregoing Rider:

My close relatives are as follows: (list all adult children and siblings and their addresses).

____________________________(name) ______________________(relationship) _______________________________________________________(address)

____________________________(name) ______________________(relationship)  _______________________________________________________(address)

____________________________(name) ______________________(relationship)  _______________________________________________________(address)

____________________________(name) ______________________(relationship)  _______________________________________________________(address)

____________________________(name) ______________________(relationship)  _______________________________________________________(address)

______ a separate sheet attached hereto names additional persons I desire to be informed of any hearing to have me declared incompetent

I direct that no one shall be appointed as my legal Guardian unless and until these individuals have been properly served notice of any hearing to have me declared incompetent in accordance with relevant laws.

I further direct that none of the above individuals shall ever be barred from contacting me by any and all means, including, but not limited to: mail, phone, fax, in person, as long as I indicate a desire to see those individuals.

Exception: ____________________________________________________(names)
No Guardian of mine shall ever ban a person from seeing me on the grounds it “agitates me”–as long as I indicate a desire to see, phone, email, etc. that person.

I shall not be banned from using a phone to call a family member.  I shall be provided with my own cell phone at all times.

No Guardian shall keep me apart from my family or isolated.  If a family member comes calling during reasonable visiting hours (noon to 8 pm or ___________________state otherwise), they shall be given access to me that day or the day following if I am at home.

I shall not be forced to take  “psychotropic drugs” to “calm me down” if I am not in fact violent or a danger to myself or others.

I shall not be placed in a nursing home as long as I have funds to stay at home with a hired nurse.  My house may be further encumbered to provide funds.  Any Guardian that attempts to sell my home to place me in a nursing home will NOT inherit under my will, and they may be immediately removed by any relative willing to take me in.  That relative will have an increased share in my estate, as further specified in my will.  (Note this provision must also be put in your will.  See a lawyer to have this done).  I direct that if I am a wander risk or a fall risk, that I stay in my home and my Guardian purchase appropriate electronic alarms so I do not leave without supervision, and I do not get out of a chair or bed without assistance.  These are NOT reasons to place me in a nursing home).

I direct that even if I am declared incompetent, that I stay in my home and that the following relatives may continue to live in my home and will not be evicted by the Probate Court:

_______________________________________________________________________
(you may wish to list a spouse or minor children or grandchildren).

If any Guardianship is filed against me, I do not want a court appointed lawyer to represent me, I desire the following attorneys have access to me for the purposes of fighting the guardianship and determining that my Guardian acts in accordance with my wishes:

_________________________________________________________(name & address)

if that lawyer cannot or will not act, then please contact:

_________________________________________________________(name & address)

________ (initials) No lawyer I name shall be disqualified because he or she drafted a document for another family member, engaged in litigation for another family member, notarized a document, etc.  I hereby waive any such conflict to the fullest extent the laws allow me to do so.  Any relative presenting or advocating such a conflict will not inherit under my will.  (Provision must also appear in your will–see a lawyer).

_______ (initials) I further direct that my lawyer ensure that no GAL or judge be used on my Estate who has been listed on NAGSA’s website pages entitled “WANTED!”  My attorney is directed to seek/remove any such GAL or judge involved in my case.

I have carefully inventoried my valuable possessions and have taken photos of these items and provided them to my attorney.  I promise to update my inventory on at least a yearly basis.  If they are missing, I ask that law enforcement investigate.

I herewith approve this Rider as further advance directives and as if fully incorporated in the foregoing Power of Attorney for Health Care.

Signed: _________________________________

Name printed: ____________________________________

 
JoAnne

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