Fillable Printable 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