Iowa Medical Power of Attorney
This legal document empowers an individual, known as the "Attorney-in-Fact," to make health care decisions on behalf of the person executing the document, referred to as the "Principal," when they are unable to do so themselves. This authority is recognized under Iowa Code Chapter 144B, ensuring decisions can be made according to the Principal's wishes.
Principal Information:
- Full Name: ___________________________
- Address: _____________________________
- City: _______________ State: IA Zip: _________
- Phone Number: ________________________
- Date of Birth: ________________________
Attorney-in-Fact Information:
- Full Name: ___________________________
- Address: _____________________________
- City: _______________ State: ______ Zip: _________
- Phone Number: ________________________
- Alternate Contact Number: _______________
In accordance with Iowa Code Chapter 144B, the Principal appoints the Attorney-in-Fact to make health care decisions on their behalf should they become unable to participate in medical decision making. The scope of this authority includes, but is not limited to, the following:
- Consenting or refusing consent to any medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Selecting or discharging health care providers and institutions.
- Approving or disapproving diagnostic tests, surgical procedures, and programs of medication.
- Deciding on the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.
Special Instructions (if any):
The authority granted in this document shall commence upon the incapacity of the Principal to make decisions regarding their own health care and shall continue until revoked.
Signature of Principal: ___________________________
Date: _______________
This document must be signed in the presence of two witnesses, who are not the spouse, children, heirs, or beneficiaries of the Principal, or health care providers directly serving the Principal. Alternatively, it can be notarized for validity.
Witness 1 Signature: ___________________________
Address: _____________________________________
Witness 2 Signature: ___________________________
Address: _____________________________________