144B.5 - DURABLE POWER OF ATTORNEY FOR HEALTH CARE -- FORM.
144B.5 DURABLE POWER OF ATTORNEY FOR HEALTH CARE --
FORM.
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, 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 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.
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. Section History: Recent Form
91 Acts, ch 140, §5; 2008 Acts, ch 1051, §5, 22