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Medical Power Of Attorney 121 - Iowa
| Medical Power Of Attorney Form. This is a Iowa form and can be used in Miscellaneous Statewide . |
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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 (Medical Power of Attorney) I,_________________________________________, born_________________________, designate ___________________________________________________________________________________ ___________________________________________________________________________________ (Type or Print) Name of Agent, Street Address, City, State, Zip Code and Phone Number 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. I hereby revoke all prior Durable Powers Of Attorney for Health Care Decision. OPTIONAL: If the person designated as agent above is unable to serve, I designate the following person to serve instead: ___________________________________________________________________________________ ___________________________________________________________________________________ (Type or Print) Name of Alternate, Street Address, City, State, Zip Code and Phone Number OPTIONAL: ADDITIONAL PROVISIONS - Insert specific instructions or statement of desires (if any): YES__ NO__ In the event that medical professionals determine that I may be an organ donor, I agree to the use of life-sustaining procedures, including a ventilator, for the sole purpose and time period required to complete the organ donation. Nothing in this paragraph shall be construed to expand or detract from the laws related to anatomical gifts as outlined in the Iowa Code, Chapter 142C. The purpose of this paragraph is to practically and medically make organ donation possible. Signed this ____day of __________________, _____. _____________________________________ Your Signature (Declarant/Principal) _____________________________________ _____________________________________ Address, Street, City, State and Zip _____________________________________ Type or Print Your Name This Power of Attorney must be witnessed by two persons or notarized. STATE OF _______________________, COUNTY OF _______________________ This instrument was acknowledged before me on _________________________________, by __________________________________________________________________________________. _______________________________ , Notary Public © The Iowa State Bar Association 2011 IOWADOCS® 121 Durable Power of Attorney for Health Care Decisions Revised June 2011 American LegalNet, Inc. www.FormsWorkFlow.com Durable Power of Attorney for Health Care Decisions Form for _______________________________________. 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. WITNESS FORM ____________________________________ Signature of First Witness ____________________________________ Signature of Second Witness ____________________________________ Type or Print Name of Witness ____________________________________ Type or Print Name of Witness ____________________________________ ____________________________________ Street Address, City, State and Zip Code _____________________________________ ____________________________________ Street Address, City, State and Zip Code American LegalNet, Inc. www.FormsWorkFlow.com AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO NOMINATED HEALTH CARE ATTORNEY-IN-FACT Pursuant to the terms of a Durable Power of Attorney, Health Care Decisions, (or Combined Living Will and Medical Power of Attorney) (HCPOA) dated ______________________________, in which the undersigned is the grantor, the power becomes effective in the event of my disability or incapacity. AUTHORIZATION TO RELEASE INFORMATION: I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company and the Medical Information Bureau, Inc., or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services, to give, disclose, and release to the person or persons designated in this document to act as my agent such of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition (including all specially protected health information relating to each of the following conditions specifically authorized by me to be disclosed by marking the box with an "X" or a check mark: ___sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), and human immunodeficiency virus (HIV); ___behavioral and mental health; and ___alcohol, drug and other substance abuse) Signature of Principal Date relating to my ability to make health care decisions. The purpose of this request is to assist in determining whether the person designated to act as my agent should act as my agent. This authorization expires when I die or when revoked by me by a written revocation signed by me and delivered to the entity from which information is being requested prior to the time information is being requested. I understand I can revoke this authorization by delivering a written statement of revocation to any entity I have authorized to give, disclose and release information. The revocation is effective only as to those entities to whom the written statement revocation is given and only after the time of delivery. I also understand that I have the right to inspect the disclosed information at a
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