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Iowa Advance Directive Form

An Iowa advance directive is a legal document that allows a person to nominate a healthcare agent to make healthcare decisions on their behalf. The form authorizes the agent to make these decisions when the principal becomes unable, in the judgment of an attending physician, to make them. The document also allows the principal to outline wishes for medical procedures and end-of-life treatment.

Signing Requirements (§ 144B.3) – Two (2) witnesses or a notary public.

Sample

Durable Power of Attorney for Health Care Decisions

I, [NAME], (date of birth: [DAY] day of [MONTH], [XXXX]), select as my Health Care Agent:
Name: [HEALCH CARE AGENT NAME]
Home: [HEALTH CARE AGENT HOME PHONE]
Cell: [HEALTH CARE AGENT CELL PHONE]
Address: [HEALTH CARE AGENT ADDRESS]

I give to my agent the power to make health care decisions for me. This power exists only when I am not able, in the judgment of my health care provider, to make my own health care decisions. My Health Care Agent must act consistently with my desires as stated in this form or otherwise made known.

I understand my Health Care Agent:

  • Will make choices for me only after I cannot make them myself in the judgment of my health care provider.
  • Can tell my health care provider to stop giving me health care, even if it is needed to keep me alive.
  • Can make decisions about all aspects of my care including but not limited to immunizations and vaccinations.
  • Can choose my health care providers, including hospitals, doctors, and end-of-life care.
  • Can look at my medical records and share my health care information as permitted.
  • Can sign releases or other forms about my medical treatment.
  • Can decide if I should join a research study.

I now cancel all prior Durable Powers Of Attorney for Health Care Decisions.

Principal’s Signature: _____________________ Date: [DAY] day of [MONTH], 20[XX]

Print Name:  _____________________________________________________________

Address: ________________________________________________________________

1ST WITNESS

Witness’s Signature: _____________________ Date: [DAY] day of [MONTH], 20[XX]

Print Name:  _____________________________________________________________

Address: ________________________________________________________________

2ND WITNESS

Witness’s Signature: _____________________ Date: [DAY] day of [MONTH], 20[XX]

Print Name:  _____________________________________________________________

Address: ________________________________________________________________