Iowa Durable Medical Power of Attorney Form

Iowa Durable Medical Power Of Attorney Form document requires the signatures of a notary or two witnesses who must be over 18 years of age and not facility providers for the principal. The Power Of Attorney form provides the principal with the power to make decisions over their health care when they are incapacitated through illnesses such as a coma or Alzheimer`s disease. Using an `Agent` to make decisions for them the principal can still controll how they receive medical health care.  The document is in accordance with US statutes § 144B.1 to .12 .

How to Write

Declaration Relating To Life Sustaining Procedures

1) The principal`s,agent`s and alternative agent`s personal details must be entered.

  • Name of principal.
  • Principal`s date of birth.
  • Name of agents.
  • Address of agents.
  • ZIP code of agents.
  • Telephone number of agents.

 

Life Sustaining Procedures

The principal must express their wishes regarding life sustaining procedures.

  • Check box either `Yes` or `No` with regards to receiving life sustaining procedures.
  • Name of principal.
  • Principals signature.
  • Principals address.
  • Principal`s ZIP code.
  • Date.

 

Witnesses

The details of the witnesses and notary must be entered.

  • State.
  • County.
  • Date.
  • Name of notary.
  • Signature of principal.
  • Signature of witnesses.
  • Name of witnesses.
  • Address of witnesses.
  • Zip code of witnesses.

 

Authorization Of Medical Information.

The principal must provide authority for the relevant personal information to be released by the agent to the health carers.

  • Date.
  • Check boxes to denote specific information to be shared.
  • Signature of principal.
  • Date.

 

Authorization Of Agent

The principal must enter their personal details to give authority to the agent.

  • Date.
  • Signature.