1. A durable power of attorney for health care executed pursuant to this chapter may, but need not, be in the following form:

 I hereby designate ………………………….. 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 or attending physician assistant, 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 law of this state, to consent to my physician or physician assistant 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, 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.
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Terms Used In Iowa Code 144B.5

  • following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
  • Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. Source: OCC
  • State: means a state, territory, or possession of the United States, the District of Columbia, or the Commonwealth of Puerto Rico. See Iowa Code 152E.3
 2. In addition to the foregoing, the principal may provide specific instructions in the document conferring the durable power of attorney for health care, consistent with the provisions of this chapter.
 3. The principal may include a statement indicating that the designated attorney in fact has been notified of and consented to the designation.
 4. A durable power of attorney for health care may designate one or more alternative attorneys in fact.
 5. A durable power of attorney for health care may include a declaration under chapter 144C that names a designee and alternate designees who may be different persons than the attorney in fact or alternate attorneys in fact who are designated in the durable power of attorney for health care.