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Iowa Advance Health Directive
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Iowa Advance Health Directive

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  • 1. INSTRUCTIONS ———— PRINT YOUR NAME AND ADDRESS PRINT THE NAME, ADDRESS AND TELEPHONE NUMBERS OF YOUR ATTORNEY IN FACT PRINT THE NAME, ADDRESS AND TELEPHONE NUMBERS OF YOUR ALTERNATE ATTORNEY IN FACT © 2000 PARTNERSHIP FOR CARING, INC. IOWA DURABLE POWER OF ATTORNEY FOR HEALTH CARE ———————————— I, ____________________________________________________________________, (name) of _____________________________________________________________________ (address) hereby appoint ________________________________________________________ (name of attorney in fact) _______________________________________________________________________ (address) _______________________________________________________________________ (home telephone number) (work telephone number) as my attorney in fact (my “agent”) 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. In the event the person I designate above is unable, unwilling or unavailable to act as my health care agent, I hereby designate___________ _______________________________________________________________________ (name of successor attorney in fact) _______________________________________________________________________ (address) ______________________________________________________________________. (home telephone number) (work telephone number) 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 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 the provision of any care, treatment, service, or procedure to maintain,
  • 2. ADD PERSONAL INSTRUCTIONS (IF ANY) PRINT YOUR NAME AND THE DATE SIGN THE DOCUMENT WITNESSING PROCEDURE ———— TWO WITNESSES OR A NOTARY PUBLIC MUST SIGN YOUR DOCUMENT © 2000 PARTNERSHIP FOR CARING, INC. 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. Optional instructions: I, _____________________________________________________________________, the principal, sign my name to this instrument this ______ day of _________________, 20 _____, and being first duly sworn, do (day) (month) (year) hereby declare to the undersigned that I am eighteen years of age or older, of sound mind, and under no undue constraint or influence. ___________________________________ (principal) WITNESS STATEMENT I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this durable power of attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud or undue influence. I am not the person designated as attorney in fact by this document, nor am I the principal’s health care provider or an employee of the principal’s health care provider. I am at least eighteen years of age. IOWA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 2 OF 3
  • 3. WITNESS #1 WITNESS #2 ONE WITNESS MUST ALSO AGREE WITH THIS STATEMENT AND SIGN HERE OR A NOTARY PUBLIC MUST COMPLETE THIS SECTION © 2000 PARTNERSHIP FOR CARING, INC. Witness #1 Signature _________________________________________ Date _____________ Print Name ___________________________________________________________ Telephone Number ___________________________________________________ Residence Address ____________________________________________________ Witness #2 Signature _________________________________________ Date _____________ Print Name ___________________________________________________________ Telephone Number ___________________________________________________ Residence Address ____________________________________________________ I further declare that I am not a relative of the principal by blood, marriage or adoption (within the third degree of consanguinity). _________________________________________ (witness’ signature) - OR - NOTARY The state of Iowa ) ) ss. The County of _______________ ) Signed and sworn to before me by ______________________________, the principal, this _____ day of _____________________, 20_____. (SEAL) _________________________________________ (notary public) IOWA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 3 OF 3 Courtesy of Partnership for Caring, Inc. 6/96 1620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455
  • 4. IOWA DECLARATION —————————— If I should have an incurable or irreversible condition that will 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 my 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 withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. Additional, specific directions (if any): Signed this __________ day of ____________________________, ____________. (day) (month) (year) Signature ____________________________________________________________ City, County and State of Residence __________________________________ _______________________________________________________________________ INSTRUCTIONS ———— ADD PERSONAL INSTRUCTIONS (IF ANY) SIGN AND DATE YOUR DOCUMENT AND PRINT YOUR PLACE OF RESIDENCE © 2000 PARTNERSHIP FOR CARING, INC.
  • 5. WITNESSES: The declarant is known to me and voluntarily signed this document in my presence. Witness ______________________________________________________________ Address ______________________________________________________________ Witness ______________________________________________________________ Address ______________________________________________________________ I further declare that I am not a relative of the declarant by blood, marriage or adoption (within the third degree of consanguinity). _________________________________________ (signature of first or second witness) - OR - ACKNOWLEDGMENT BY NOTARY PUBLIC: On ________________, before me came __________________________________, (name of declarant) whom I know to be such person, and the declarant did then there execute this declaration. Sworn to before me this _______ day of ______________________, 20______. _________________________________________ (notary public) WITNESSING PROCEDURE ———— EITHER TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES (ONE WITNESS MUST ALSO AGREE WITH THIS STATEMENT AND SIGN HERE) OR A NOTARY PUBLIC MUST COMPLETE THIS SECTION OF YOUR DOCUMENT © 2000 PARTNERSHIP FOR CARING, INC. IOWA DECLARATION — PAGE 2 OF 2 Courtesy of Partnership for Caring, Inc. 6/96 1620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455