§ 144B.5 — Durable power of attorney for health care — form

Iowa § 144B.5

• Jurisdiction: Iowa
• Title IV: PUBLIC HEALTH
• Ch. 144B: DURABLE POWER OF ATTORNEY FOR HEALTH CARE

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1. A durable power of attorney for health care executed pursuant to this chapter may, but
need not, be in the following form:
I hereby designate ................................ 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 or attending physician
assistant, 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 law
of this state, to consent to my physician or physician assistant not
givinghealthcareorstoppinghealthcarewhichisnecessarytokeep
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 the provision of 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.
2. In addition to the foregoing, the principal may provide specific instructions in the
3 DURABLE POWER OF ATTORNEY FOR HEALTH CARE, §144B.8
document conferring the durable power of attorney for health care, consistent with the
provisions of this chapter.
3. The principal may include a statement indicating that the designated attorney in fact
has been notified of and consented to the designation.
4. A durable power of attorney for health care may designate one or more alternative
attorneys in fact.
5. A durable power of attorney for health care may include a declaration under chapter
144C that names a designee and alternate designees who may be different persons than the
attorney in fact or alternate attorneys in fact who are designated in the durable power of
attorney for health care.