Illinois Medical Power Of Attorney

Information you will need

• Quality and Length of Life
• Principal Name
• Principal Full Address
• Agent Name
• Agent Address
• Agent Phone Number
• Successor Agent Name, Address, and Phone Number
• Specific Limitations
• Witness Name
• Witness Address
• Guardian of Person
• Authorization of Agent
• Witness Attestation
• Witness Signature Date
• Principal Signature Date

Completed by the agent and the principal and the provider.

The form includes 2 signature lines, a witness section.

The document text refers to the laws of Illinois.