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Fillable Printable Durable Power of Attorney for Health Care Decisions - Iowa

Fillable Printable Durable Power of Attorney for Health Care Decisions - Iowa

Durable Power of Attorney for Health Care Decisions - Iowa

Durable Power of Attorney for Health Care Decisions - Iowa

GENERAL INFORMATION REGARDING DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
1. Health care’ means any care, treatment, service, or procedure to maintain, diagnose, or
treat an individual’s physical or mental condition. Health care decisions also include
decisions about life-sustaining procedures, which means any medical procedure, treatment,
or intervention which utilizes mechanical or artificial means to sustain, restore, or
supplement a spontaneous vital function, and when applied to a person in a terminal
condition, would serve only to prolong the dying process. Life sustaining procedure does
not include administration of medication or performance of any medical procedure deemed
necessary to provide comfort care or to alleviate pain.
2. The following individuals shall not be designated as the attorney in fact to make health
care decisions under a durable power of attorney for health care:
1. a health care provider attending the principal on the date of execution;
2. an employee of such a health care provider unless the individual to be designated is
related to the principal by blood, marriage, or adoption within the third degree of
consanguinity.
3. The power of attorney for health care decisions may be revoked at any time and in any
manner by which the principal declarant is able to communicate the intent to revoke,
without regard to mental or physical condition. A revocation is only effective as to the
attending health care provider upon its communication to the provider by the principal
declarant or by another to whom the principal/declarant has communicated the revocation.
4. It is the responsibility of the principal declarant to provide the attending health care
provider with a copy of this document.
SUGGESTIONS AFTER FORM IS PROPERLY SIGNED, WITNESSED OR NOTARIZED
1. Provide a copy to the designated attorney-in-fact (agent) and to alternate
designated attorney-in-fact (if any).
2. Place original in a safe place known and accessible to family members or close friends.
3. Provide a copy to your doctor.
4. Provide a copy(s) to family member(s).
NOTE: For additional copies of this form, go to the Iowa Legal Aid Website (iowalegalaid.org). You may go
directly to a pdf file of this document by putting www.iowalegalaid.org/link.cfm?900 in your browser.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
(Medical Power of Attorney)
I, ______________________________, hereby designate ____________________________, of
_____________________________________________________________________________,
(address, city, state and telephone number)
as my attorney-in-fact (my agent) and give to my agent the power to make health care decisions for me. This
power exists only when I am unable, in the judgment of my attending physician, to make those health care
decisions. The attorney-in-fact must act consistently with my desires as stated in this document or otherwise
made known.
Except as otherwise specified in this document, this document gives my agent the power, where
otherwise consistent with the laws of the State of Iowa, to consent to my physician not giving health care or
stopping health care which is necessary to keep me alive.
This document gives my agent power to make health care decisions on my behalf, including to
consent, to refuse to consent, or to withdraw consent to any care, treatment, service or procedure to maintain,
diagnose or treat a physical or mental condition. This power is subject to any statement of my desires and any
limitations included in this document. My agent has the right to examine my medical records and to consent
to disclosure of such records. I also appoint my agent as my Personal Representative (as that term is used in
the Health Insurance Portability and Accountability Act of 1996, as amended, and its promulgating
regulations) and to have access to my personally identifiable health care and related information of all kinds in
any form, and to execute any other document that may be required or requested in order to do so.
Additional provisions:
If the person designated as agent above is unable or unwilling to serve, I designate the following person to
serve as my agent with the power to make health care decisions for me:
______________________________________________________________________________
______________________________________________(name, address and telephone number).
Signed this ____ day of_________________, _______.
__________________________________________
(Signature of Declarant/Principal)
Address: __________________________________
__________________________________________
SSN:#____________________________________
IMPORTANT NOTE: THIS DOCUMENT MUST BE SIGNED BEFORE A NOTARY PUBLIC OR TWO
WITNESSES. IF YOU HAVE QUESTIONS REGARDING THIS FORM OR NEED ASSISTANCE TO
COMPLETE IT, YOU SHOULD CONSULT AN ATTORNEY.
(OVER)
NOTARY PUBLIC FORM
STATE OF IOWA, COUNTY OF _____________, SS:
On this_____ day of _____________, _______, before me, the undersigned, a Notary Public in and
for said state, personally appeared _____________________________________, to me known to be the
person named in and who executed the foregoing instrument and acknowledged that he/she executed the same
as his/her voluntary act and deed.
____________________________________
Notary Public in and for the State of Iowa
WITNESS FORM
We, the undersigned, hereby state that:
C we signed this document in the presence of each other and the Declarant;
C we witnessed the signing of the document by the Declarant or by another person acting on behalf of
the Declarant at the direction of the Declarant;
C neither of us are health care providers who are presently treating the Declarant, or employees of such a
health care provider;
C we are both at least 18 years of age; and
C at least one of us is not related to the Declarant by blood, marriage or adoption.
________________________________________
Signature of 1st Witness
________________________________________
(Type or Print Name of Witness)
________________________________________
Street Address
________________________________________
City State Zip Code
________________________________________
Signature of 2nd Witness
________________________________________
(Type or Print Name of Witness)
________________________________________
Street Address
________________________________________
City State Zip Code
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