Iowa Medical Power of Attorney Template
This Medical Power of Attorney is made in accordance with Iowa Code Chapter 144B. It allows you to appoint someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Statement of Desires:
If I am unable to make my own medical decisions, I authorize my agent to make decisions regarding my healthcare, including but not limited to:
- Choosing healthcare providers.
- Accepting or refusing treatment.
- Accessing my medical records.
- Making decisions about life-sustaining treatment.
Effective Date:
This Medical Power of Attorney is effective immediately upon signing, unless I specify otherwise: ____________________.
Revocation of Prior Powers of Attorney:
This document revokes any prior Medical Powers of Attorney I may have executed.
Signatures:
By signing below, I confirm that I am of sound mind and voluntarily appoint the agent named above.
Principal Signature: _________________________
Date: _____________________________________
Witnesses:
Two witnesses are required. They must not be related to you or your agent.
- Witness 1 Signature: ____________________
- Witness 1 Name: ______________________
- Witness 2 Signature: ____________________
- Witness 2 Name: ______________________
Notarization:
If desired, this document may be notarized.
Notary Public Signature: ____________________
Date: _____________________________________