Illinois Compiled Statutes 755 ILCS 9/50 – Agreement instrument
If you agree to provide support to the principal, you have a duty to:
(1) act in good faith;
Terms Used In Illinois Compiled Statutes 755 ILCS 9/50
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
(2) act within the authority granted in this
agreement;
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(4) avoid conflicts of interest.
I, (insert principal’s name), make this agreement of my own free will.
I agree and designate that the following individual is my supporter:
Name: …………………………………………….
Address: ………………………………………….
Phone Number: ……………………………………..
Email Address: …………………………………….
My supporter is to help me make decisions for myself and may help me with making everyday life decisions relating to the following:
(Yes/No) obtaining food, clothing, and shelter.
(Yes/No) taking care of my physical and emotional health.
(Yes/No) managing my financial affairs.
(Yes/No) applying for public benefits.
(Yes/No) helping me find work.
(Yes/No) assisting with residential services.
(Yes/No) helping me with school.
(Yes/No) helping me advocate for myself.
My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may:
(1) help me access, collect, or obtain information
that is relevant to a decision, including medical, psychological, financial, educational, housing, and treatment records;
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an informed decision; and
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persons.
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I want my supporter to have:
(Yes/No) A release allowing my supporter to see
protected health information under the Health Insurance Portability and Accountability Act of 1996 is attached.
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confidential information under the Mental Health and Developmental Disabilities Confidentiality Act is attached.
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educational records under the Family Educational Rights and Privacy Act of 1974 and the Illinois School Records Act is attached.
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substance abuse records under Confidentiality of Alcohol and Drug Abuse Patient Records regulations is attached.
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This supported decision-making agreement is effective immediately and will continue until (insert date) or until the agreement is terminated by my supporter or me or by operation of law.
Signed this …. day of …….., 20….
(Signature of Principal) (Printed name of principal)
I, (name of supporter), consent to act as a supporter under this agreement.
(Signature of supporter) (Printed name of supporter)
(Witness 1 signature) (Printed name of witness 1)
(Witness 2 signature) (Printed name of witness 2)
IF A PERSON WHO RECEIVES A COPY OF THIS AGREEMENT OR IS AWARE OF THE EXISTENCE OF THIS AGREEMENT HAS CAUSE TO BELIEVE THAT THE ADULT WITH A DISABILITY IS BEING ABUSED, NEGLECTED, OR EXPLOITED BY THE SUPPORTER, THE PERSON SHALL REPORT THE ALLEGED ABUSE, NEGLECT, OR EXPLOITATION TO THE ADULT PROTECTIVE SERVICES HOTLINE: 1-866-800-1409, 1-888-206-1327 (TTY).”
This form is not intended to exclude other forms or agreements that identify the principal, supporter, and types of supports.