iowa advance health directive
DESCRIPTION
TRANSCRIPT
INSTRUCTIONS————
PRINT YOURNAME ANDADDRESS
PRINT THENAME,
ADDRESS ANDTELEPHONE
NUMBERS OFYOUR
ATTORNEY INFACT
PRINT THENAME,
ADDRESS ANDTELEPHONE
NUMBERS OFYOUR
ALTERNATEATTORNEY IN
FACT
© 2000PARTNERSHIP 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 myattending physician, to make those health care decisions. The attorneyin fact must act consistently with my desires as stated in this documentor 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 myagent the power, where otherwise consistent with the law of this state, toconsent to my physician not giving health care or stopping health carewhich is necessary to keep me alive.
This document gives my agent power to make health care decisions on mybehalf, including to consent, to refuse to consent, or to withdraw consentto the provision of any care, treatment, service, or procedure to maintain,
ADD PERSONALINSTRUCTIONS
(IF ANY)
PRINT YOURNAME AND THE
DATE
SIGN THEDOCUMENT
WITNESSINGPROCEDURE————
TWOWITNESSES OR
A NOTARYPUBLIC MUST
SIGN YOURDOCUMENT
© 2000PARTNERSHIP FOR
CARING, INC.
diagnose, or treat a physical or mental condition. This power is subject toany statement of my desires and any limitations included in thisdocument.
My agent has the right to examine my medical records and to consent todisclosure 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)
h e reby 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 ispersonally known to me, that he/she signed or acknowledged thisdurable power of attorney in my presence, and that he/she appears tobe of sound mind and under no duress, fraud or undue influence. I amnot the person designated as attorney in fact by this document, nor am Ithe principal’s health care provider or an employee of the principal’shealth care provider. I am at least eighteen years of age.
IOWA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 2 OF 3
WITNESS #1
WITNESS #2
ONE WITNESSMUST ALSOAGREE WITH
THISSTATEMENT
AND SIGN HERE
OR
A NOTARYPUBLIC MUST
COMPLETE THISSECTION
© 2000PARTNERSHIP 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. 6/961620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455
IOWA DECLARATION
——————————
If I should have an incurable or irreversible condition that will re s u l teither in death within a relatively short period of time or a state ofp e rmanent unconsciousness from which, to a reasonable degree ofmedical certainty, there can be no recovery, it is my desire that my lifenot be prolonged by the administration of life-sustaining procedures. If Iam unable to participate in my health care decisions, I direct myattending physician to withhold or withdraw life-sustaining proceduresthat merely prolong the dying process and are not necessary to mycomfort or freedom from pain.
Additional, specific directions (if any):
Signed this __________ day of ____________________________, ____________.(day) (month) (year)
S i g n a t u re ____________________________________________________________
City, County and State of Residence __________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
INSTRUCTIONS————
ADD PERSONALINSTRUCTIONS
(IF ANY)
SIGN AND DATEYOUR
DOCUMENT ANDPRINT YOUR
PLACE OFRESIDENCE
© 2000PARTNERSHIP FOR
CARING, INC.
WITNESSES:
The declarant is known to me and voluntarily signed this document inmy presence.
Wi t n e s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address ______________________________________________________________
Wi t n e s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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 thereexecute this declaration.
Sworn to before me this _______ day of ______________________, 20______.
_________________________________________(notary public)
WITNESSINGPROCEDURE————
EITHER
TWOWITNESSES
MUST SIGN ANDPRINT THEIRADDRESSES
(ONE WITNESSMUST ALSOAGREE WITH
THIS STATEMENTAND SIGN HERE)
OR
A NOTARYPUBLIC MUST
COMPLETE THISSECTION OF
YOURDOCUMENT
© 2000PARTNERSHIP FOR
CARING, INC.
IOWA DECLARATION — PAGE 2 OF 2
Courtesy of Partnership for Caring, Inc. 6/961620 Eye Street, NW Suite 202 Washington, DC 20006 800-989-9455