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Iowa __________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ ________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ ____________________________________________ Phone: ____________________________________________________________________ __________________________________________ (Declarant's Signature) _____________________________me: ____________________________________________________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ____________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Nahdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. Additional Instructions (optional): __________________________________ desire that my life not be prolonged by the administration of life-sustaining procedures. If I am unable to participate in my health care decisions, I direct my attending physician to withhold or witwill result either in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery, it is myfessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will If I should have an incurable or irreversible condition that r situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax profrom time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particula provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary n executed pursuant to this chapter may, but need not, be in the following form: (Form included below). [_] These forms are provided "as is" and no implied or express warranties have been made or areis in compliance with the Living Will Information & Instructions ­ Page 2 federal department of veterans affairs advance directive requirements shall be deemed valid and enforceable. 5. A declaratioforceable in this state, to the extent the declaration or similar document is consistent with the laws of this state. A declaration or similar document executed by a veteran of the armed forces which ies with this chapter and is valid. 4. A declaration or similar document executed in another state or jurisdiction in compliance with the law of that state or jurisdiction shall be deemed valid and enttending physician or health care provider with the declaration. An attending physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration complion. (3) An individual who is less than eighteen years of age. b. Is acknowledged before a notarial officer within this state. 3. It is the responsibility of the Declarant to provide the Declarant's anot be witnesses for a declaration: (1) A health care provider attending the Declarant on the date of execution. (2) An employee of a health care provider attending the Declarant on the date of execut. At least one of the witnesses shall be an individual who is not a relative of the Declarant by blood, marriage, or adoption within the third degree of consanguinity. The following individuals shall uals who, in the presence of each other and the Declarant, witnessed the signing of the declaration by the Declarant or by another person acting on behalf of the Declarant at the Declarant's direction of the Declarant at the direction of the Declarant, must contain the date of its execution, and must be witnessed or acknowledged by one of the following methods: a. Is signed by at least two individ the Declarant's condition is determined to be terminal and the Declarant is not able to make treatment decisions. 2. The declaration must be signed by the Declarant or another person acting on behalfining procedures. 1. A competent adult may execute a declaration at any time directing that life-sustaining procedures be withheld or withdrawn. The declaration shall be given operative effect only if is based on Chapter 144A of the Iowa Statutes For your convenience, we have included useful excerpts from the Iowa Statutes relating to Living Wills. 144A.3 Declaration relating to use of life-susta____________________________ -2- Information and Instructions Iowa Living Will This package contains (1) Information and Instruction for Iowa Living Will; (2) Iowa Living Will. This Iowa Living Willeen appointed as alternate attorney in fact by the Declarant and consent to such designation _____________________________________________ (Signature of Alternate Attorney in Fact) Print Name: _______lternate Attorney in Fact (optional) I have read the above Durable Power of Attorney for Health Care signed by ________________________________________ (name of Declarant) and understand that I have bney in fact by the Declarant and consent to such designation _____________________________________________ (Signature of Attorney in Fact) Print Name: ___________________________________ Consent of Aact (optional) I have read the above Durable Power of Attorney for Health Care signed by ________________________________________ (name of Declarant) and understand that I have been appointed as attor___________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Consent of Attorney in F__ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ ____________________________________________________________________ Signed: ____________________________________________________________________ Dated: ______________________________ -1- ______________________________________________ ______________________________________________________________________________ Name: ____________________________________________________________________ Address: _____________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ht to examine my medical records and to consent to disclosure of such records. Additional instructions (or write none): ______________________________________________ _________________________________e, 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 rigalive. 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, servic this document gives my agent the power, where otherwise consistent with the law of this state, to consent to my physician not giving health care or stopping health care which is necessary to keep me ian, 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,t, I hereby designate ________________________________________________________________ as my alternate attorney in fact. This power exists only when I am unable, in the judgment of my attending physic______________________as my attorney in fact and give to my agent the power to make health care decisions for me. If the above named person is not available or is unable to serve as my attorney in facand use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Durable Power of Attorney for Health Care I hereby designate ___________________________________also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase nd should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should teness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you aisions. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or compleevocation of a durable power of attorney shall have no effect upon subsequent health care decisions made in accordance with accepted principles of law and standards of medical care governing those decl liability for acting in good faith reliance upon the durable power of attorney for health care unless the individual has actual knowledge of the revocation. 5. The fact of execution and subsequent rle power of attorney for health care. 4. If authority granted by a durable power of attorney for health care is revoked under this section, an individual is not subject to criminal prosecution or civicipal is presumed to have the capacity to revoke a durable power of attorney for health care. 3. Unless it provides otherwise, a valid durable power of attorney for health care revokes any prior durabprovider by the principal or by another to whom the principal has communicated revocation. The health care provider shall document the revocation in the treatment records of the principal. 2. The prin care provider orally or in writing while that provider is engaged in providing health care to the principal. A revocation is only effective as to a health care provider upon its communication to the nicate the intent to revoke, without regard to mental or physical condition. Revocation may be by notifying the attorney in fact orally or in writing. Revocation may also be made by notifying a healthe of consanguinity. 144B.8 Revocation of durable power of attorney. 1. A durable power of attorney for health care may be revoked at any time and in any manner by which the principal is able to commuyee of a health care provider attending the principal on the date of execution unless the individual to be designated is related to the principal by blood, marriage, or adoption within the third degred as the attorney in fact to make health care decisions under a durable power of attorney for health care: -2- 1. A health care provider attending the principal on the date of execution. 2. An emplotment of veterans affairs advance directive requirements shall be deemed valid and enforceable. 144B.4 Individua ls ineligible to be attorney in fact. The following individuals shall not be designatee extent the document is consistent with the laws of this state. A durable power of attorney or similar document executed by a veteran of the armed forces which is in compliance with the federal departorney for health care or similar document executed in another state or jurisdiction in compliance with the law of that state or jurisdiction shall be deemed valid and enforceable in this state, to thrable power of attorney for health care shall be an individual who is not a relative of the principal by blood, marriage, or adoption within the third degree of consanguinity. 4. A durable power of at. The individual designated in the durable power of attorney for health care as the attorney in fact. d. An individual who is less than eighteen years of age. 3. At least one of the witnesses for a duer of attorney for health care: a. A health care provider attending the principal on the date of execution. b. An employee of a health care provider attending the principal on the date of execution. cn acting on behalf of the principal at the principal's direction. (2) Is acknowledged before a notarial officer within this state. 2. The following individuals shall not be witnesses for a durable powe of the following methods: (1) Is signed by at least two individuals who, in the presence of each other and the principal, witnessed the signing of the instrument by the principal or by another persoare explicitly authorizes the attorney in fact to make health care decisions. b. The durable power of attorney for health care contains the date of its execution and is witnessed or acknowledged by ongned by the principal. -1- 144B.3 Requirements. 1. An attorney in fact shall make health care decisions only if the following requirements are satisfied: a. The durable power of attorney for health cMay 8, 1991, purporting to create a durable power of attorney for health care shall be deemed valid if the document specifically authorizes the attorney in fact to make health care decisions and is siney in fact to make health care decisions for the principal if the durable power of attorney for health care substantially complies with the requirements of this chapter. A document executed prior to age eighteen or older who has executed a durable power of attorney for health care. 144B.2 Durable power of attorney for health care. A durable power of attorney for health care authorizes the attor certified, or otherwise authorized or permitted by the law of this state to administer health care in the ordinary course of business or in the practice of a profession. 6. "Principal" means a person parenterally or through intubation. 4. "Health care decision" means the consent, refusal of consent, or withdrawal of consent to health care. 5. "Health care provider" means a person who is licensed,cedure to maintain, diagnose, or treat an individual's physical or mental condition. "Health care" does not include the provision of nutrition or hydration except when they are required to be providedalth care decisions for the principal if the principal is unable, in the judgment of the attending physician, to make health care decisions. 3. "Health care" means any care, treatment, service, or proake health care decisions on behalf of a principal and has consented to act in that capacity. 2. "Durable power of attorney for health care" means a document authorizing an attorney in fact to make heitions. For purposes of this chapter, unless the context otherwise requires: 1. "Attorney in fact" means an individual who is designated by a durable power of attorney for health care as an agent to morney for Health Care is based on Chapter 144B of the Iowa Statutes. The following are useful excerpts from the Iowa Statutes relating to the Iowa Power of Attorney for Health Care Form. 144B.1 Defin Care This package contains (1) Information and Instruction for Iowa Durable Power of Attorney for Health Care ; (2) Iowa Durable Power of Attorney for Health Care Form. This Iowa Durable Power of Attprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Iowa Durable Power of Attorney for Healthular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax ry from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particare provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vaDirective. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been made or Iowa Advance Health Care Directive This package contains both a Iowa Power of Attorney for Health Care and a Iowa Living Will. Together these forms are also sometimes known as an Advance Health Care Iowa