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Iowa (Signature of Alternate Attorney in Fact) Print Name: ___________________________________ -2- ____________ (name of Declarant) and understand that I have been appointed as alternate attorney in fact by the Declarant and consent to such designation _____________________________________________ Print Name: ___________________________________ Consent of Alternate Attorney in Fact (optional) I have read the above Durable Power of Attorney for Health Care signed by ____________________________Declarant) and understand that I have been appointed as attorney in fact by the Declarant and consent to such designation _____________________________________________ (Signature of Attorney in Fact) ____________________________________ Consent of Attorney in Fact (optional) I have read the above Durable Power of Attorney for Health Care signed by ________________________________________ (name of ___________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________ -1- _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _________________________________ Address: __________________________________________________________________ Signed: ____________________________________________________________________ Dated: _____________________________________________________________________________________ ______________________________________________________________________________ Name: _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________ any limitations included in this document. My agent has the right to examine my medical records and to consent to disclosure of such records. Additional instructions (or write none): ________________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 andalth 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 wise 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 not giving hets 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 otherson is not available or is unable to serve as my attorney in fact, I hereby designate ________________________________________________________________ as my alternate attorney in fact. This power exisalth Care I hereby designate _________________________________________________________as my attorney in fact and give to my agent the power to make health care decisions for me. If the above named pert should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Durable Power of Attorney for Hew it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this documen to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney reviey 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 from time to time and from stateinciples of law and standards of medical care governing those decisions. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitabilitedge of the revocation. 5. The fact of execution and subsequent revocation of a durable power of attorney shall have no effect upon subsequent health care decisions made in accordance with accepted prion, an individual is not subject to criminal prosecution or civil liability for acting in good faith reliance upon the durable power of attorney for health care unless the individual has actual knowldurable power of attorney for health care revokes any prior durable power of attorney for health care. 4. If authority granted by a durable power of attorney for health care is revoked under this sectrevocation in the treatment records of the principal. 2. The principal is presumed to have the capacity to revoke a durable power of attorney for health care. 3. Unless it provides otherwise, a valid ctive as to a health care provider upon its communication to the provider by the principal or by another to whom the principal has communicated revocation. The health care provider shall document the or in writing. Revocation may also be made by notifying a health care provider orally or in writing while that provider is engaged in providing health care to the principal. A revocation is only effeny time and in any manner by which the principal is able to communicate the intent to revoke, without regard to mental or physical condition. Revocation may be by notifying the attorney in fact orallye principal by blood, marriage, or adoption within the third degree of consanguinity. 144B.8 Revocation of durable power of attorney. 1. A durable power of attorney for health care may be revoked at aider attending the principal on the date of execution. 2. An employee of a health care provider attending the principal on the date of execution unless the individual to be designated is related to thattorney in fact. 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: -2- 1. A health care provan of the armed forces which is in compliance with the federal department of veterans affairs advance directive requirements shall be deemed valid and enforceable. 144B.4 Individuals ineligible to be isdiction shall be deemed valid and enforceable in this state, to the extent the document is consistent with the laws of this state. A durable power of attorney or similar document executed by a vetern within the third degree of consanguinity. 4. A durable power of attorney for health care or similar document executed in another state or jurisdiction in compliance with the law of that state or jurhan eighteen years of age. 3. At least one of the witnesses for a durable power of attorney for health care shall be an individual who is not a relative of the principal by blood, marriage, or adoptioth care provider attending the principal on the date of execution. c. The individual designated in the durable power of attorney for health care as the attorney in fact. d. An individual who is less t. The following individuals shall not be witnesses for a durable power of attorney for health care: a. A health care provider attending the principal on the date of execution. b. An employee of a heald the signing of the instrument by the principal or by another person acting on behalf of the principal at the principal's direction. (2) Is acknowledged before a notarial officer within this state. 2ins the date of its execution and is witnessed or acknowledged by one of the following methods: (1) Is signed by at least two individuals who, in the presence of each other and the principal, witnesserements are satisfied: a. The durable power of attorney for health care explicitly authorizes the attorney in fact to make health care decisions. b. The durable power of attorney for health care contahorizes the attorney in fact to make health care decisions and is signed by the principal. -1- 144B.3 Requirements. 1. An attorney in fact shall make health care decisions only if the following requiwith the requirements of this chapter. A document executed prior to May 8, 1991, purporting to create a durable power of attorney for health care shall be deemed valid if the document specifically autre. A durable power of attorney for health care authorizes the attorney in fact to make health care decisions for the principal if the durable power of attorney for health care substantially complies ess or in the practice of a profession. 6. "Principal" means a person age eighteen or older who has executed a durable power of attorney for health care. 144B.2 Durable power of attorney for health caealth care. 5. "Health care provider" means a person who is licensed, certified, or otherwise authorized or permitted by the law of this state to administer health care in the ordinary course of businf nutrition or hydration except when they are required to be provided parenterally or through intubation. 4. "Health care decision" means the consent, refusal of consent, or withdrawal of consent to hecisions. 3. "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. "Health care" does not include the provision olth care" means a document authorizing an attorney in fact to make health care decisions for the principal if the principal is unable, in the judgment of the attending physician, to make health care dnated by a durable power of attorney for health care as an agent to make health care decisions on behalf of a principal and has consented to act in that capacity. 2. "Durable power of attorney for heating to the Iowa Power of Attorney for Health Care Form. 144B.1 Definitions. For purposes of this chapter, unless the context otherwise requires: 1. "Attorney in fact" means an individual who is desigPower of Attorney for Health Care Form. This Iowa Durable Power of Attorney for Health Care is based on Chapter 144B of the Iowa Statutes. The following are useful excerpts from the Iowa Statutes relaInformation and Instructions Iowa Durable Power of Attorney for Health Care This package contains (1) Information and Instruction for Iowa Durable Power of Attorney for Health Care ; (2) Iowa Durable Iowa