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Iowa Durable Health Care Power of Attorney Form

The Iowa health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Iowa Durable Health Care Power of Attorney Form
Iowa Durable Health Care Power of Attorney Form
THE IOWA STATE BAR ASSOCIATION
Official Form No. 121
FOR THE LEGAL EFFECT OF THE USE OF
THIS FORM, CONSULT YOUR LAWYER
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
I (the "Principal") hereby designate
Last Name(Type or Print) First Name
StateCity Zip Code
(Type or Print) Street Address
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.
NOTE:
(The Principal does not have to give any specific instructions or statement of desires but
may do so.) Insert here specific instructions or statement of desires of principal (if any).
NOTE:
(The Principal may designate one or more alternates as attorney in fact but does not have
to.) If the person designated above is unable to serve,
I designate
Last Name(Type or Print) First Name
State Zip CodeCity(Type or Print) Street Address
to serve as my attorney in fact.
Signed this
Signature of Principal (Person Granting the Power of Attorney)
(Type or Print Name of Principal)
Street Address
StateCity Zip Code
This Power of Attorney must be witnessed by two persons or notarized.
COUNTY, ss:
STATE OF IOWA,
before me, the undersigned, a Notary
On this
Public in and for the State of Iowa, personally appeared
to me known to be the person named in and who executed the foregoing instrument, and acknow-
ledged that (he) (she) executed the same as (his) (her) voluntary act and deed.
, Notary Public in and for said State.
By signing this form I declare that I signed this form in the presence of the other witness and the
Principal and I witnessed the signing by the Principal or other person acting on behalf of and at the
Principal's direction.
Signature of 2nd Witness
Signature of 1st Witness
(Type or Print Name of Witness)
(Type or Print Name of Witness)
Street Address
Street Address
State Zip Code
State Zip Code City
City
(Over)
121 DURABLE POWER OF ATTORNEY FOR HEALTH CARE
Revised January, 1999
,
day of ,
day of
,
® The Iowa State Bar Association
IOWADOCS 1/99
TM
(Medical Power of Attorney)
It is strongly recommended you contact legal counsel when completing this
document.
Iowa Durable Health Care Power of Attorney Form
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