Iowa Medical Power of Attorney Template
This Iowa Medical Power of Attorney allows you to designate someone to make healthcare decisions on your behalf if you become unable to do so. This document is governed by Iowa Code Chapter 144B.
Principal Information:
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Alternate Agent (if applicable):
- Name: ____________________________
- Address: __________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Authority Granted:
The agent named above is granted the authority to make healthcare decisions on my behalf, including but not limited to:
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Choosing healthcare providers and facilities.
- Making decisions regarding life-sustaining treatment.
Effective Date:
This Medical Power of Attorney becomes effective upon my incapacity, as determined by my attending physician.
Signature:
By signing below, I confirm that I understand the contents of this document and that I am of sound mind.
______________________________
Signature of Principal
Date: ________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness 1 Name: ____________________
- Witness 1 Signature: _______________
- Date: _____________________________
- Witness 2 Name: ____________________
- Witness 2 Signature: _______________
- Date: _____________________________
Notarization (if desired):
This document may be notarized for additional validation.
______________________________
Notary Public Signature
Date: ________________________