Durable Power Of Attorney For Health Care Decisions
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1
2THE IOWA STATE BAR ASSOCIATION
FOR THE LEGAL EFFECT OF THE USE OF
Official Form No. 121
THIS FORM, CONSULT YOUR LAWYER
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
(Medical Power of Attorney)
,
I (the "Principal") hereby designate
(Type or Print) First Name
Last Name
City
State
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
(Type or Print)
First Name
Last Name
(Type or Print)
Street Address
City
State
Zip Code
to serve as my attorney in fact.
Signed this
day of
,
Signature of Principal (Person Granting the Power of Attorney)
(Type or Print Name of Principal)
Street Address
City
State
Zip Code
This Power of Attorney must be witnessed by two persons or notarized.
STATE OF IOWA,
COUNTY, ss:
,
On this
day of
before me, the undersigned, a Notary
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 1st Witness
Signature of 2nd Witness
(Type or Print Name of Witness)
(Type or Print Name of Witness)
Street Address
Street Address
State
Zip Code
City
State
Zip Code
City
(Over)
121 DURABLE POWER OF ATTORNEY FOR HEALTH CARE
® The Iowa State Bar Association
TM
Revised January, 1999
IOWADOCS
1/99
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