In the realm of personal health care planning and legal preparation, the Iowa 123 form embodies a critical tool designed to ensure individuals' wishes are respected when they can no longer voice their decisions due to severe health conditions. Crafted by The Iowa State Bar Association, this official document seamlessly combines a declaration relating to life-sustaining procedures (often referred to as a Living Will) with a Durable Power of Attorney for Health Care Decisions. It is a robust instrument that addresses two pivotal aspects: firstly, it outlines the declarant's preferences regarding the use of life-sustaining treatment in situations of terminal illness or irreversible unconsciousness, including a special consideration for comfortable and pain-free treatment. Secondly, it empowers a trusted individual, designated by the declarant, to make health care decisions on their behalf under circumstances where they are incapacitated. This form not only ensures that the declarant's health care wishes are known and could be followed but also establishes clear authorization for organ donation, subject to Iowa's regulations on anatomical gifts, making it an essential component of end-of-life planning. Importantly, the form’s effectiveness is contingent upon proper signing, witnessing, or notarization, principles which underscore the gravity and legal rigor with which such declarations are treated. Additionally, this document comes with provisions for revocation and addresses the sharing of protected health information in alignment with HIPAA, all of which are designed to give individuals peace of mind knowing their health care decisions will rest in hands they trust.
Question | Answer |
---|---|
Form Name | Iowa Form 123 |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | fillable iowa docs form 123, the iowa state bar association forms, where do i send iowa form ia123, iowa relating |
THE IOWA STATE BAR ASSOCIATION Official Form No. 123
FOR THE LEGAL EFFECT OF THE USE OF THIS FORM, CONSULT YOUR LAWYER
DECLARATION RELATING TO
(Living Will)
AND
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
(Medical Power of Attorney)
I. DECLARATION RELATING TO
If I should have an incurable or irreversible condition that will result either in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the administration of
This declaration is subject to any specific instructions or statement of desires I have added in "Additional Provisions" below.
II.POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
I,_________________________________________, born_________________________, designate
___________________________________________________________________________________
___________________________________________________________________________________
(Type or Print) Name of Agent, Street Address, City, State, Zip Code and Phone Number
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 laws of the State of Iowa, 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 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.
I hereby revoke all prior Durable Powers Of Attorney for Health Care Decision.
OPTIONAL: If the person designated as agent above is unable to serve, I designate the following person to serve instead:
___________________________________________________________________________________
___________________________________________________________________________________
(Type or Print) Name of Alternate, Street Address, City, State, Zip Code and Phone Number
OPTIONAL: ADDITIONAL PROVISIONS - Insert specific instructions or statement of desires (if any):
YES__ NO__ In the event that medical professionals determine that I may be an organ donor, I agree to the use of
Signed this ____day of __________________, _____.
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_____________________________________ |
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Your Signature (Declarant/Principal) |
_____________________________________ |
_____________________________________ |
Address, Street, City, State and Zip |
Type or Print Your Name |
IMPORTANT NOTE: THIS DOCUMENT MUST BE SIGNED OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC OR TWO WITNESSES. SEE REVERSE FOR NOTARY OR WITNESS FORMS. IF YOU WANT TO EXECUTE EITHER A LIVING WILL DECLARATION OR A MEDICAL POWER OF ATTORNEY, BUT NOT BOTH, SEPARATE FORMS ARE AVAILABLE FROM THE IOWA STATE BAR ASSOCIATION. IF YOU HAVE QUESTIONS REGARDING THIS FORM OR NEED ASSISTANCE TO COMPLETE IT, YOU SHOULD CONSULT AN ATTORNEY.
© The Iowa State Bar Association 2013 |
DECLARATION RELATING TO |
IOWADOCS® |
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS Revised August 2013 |
NOTARY PUBLIC FORM
STATE OF ____________________, COUNTY OF ______________________ ss:
This record was acknowledged before me this ______ day of ________________, _______, by
_______________________________________________________________________________.
_________________________
Signature of Notary Public
WITNESS FORM
We, the undersigned, hereby state that we signed this document in the presence of each other and the Declarant/Principal and we witnessed the signing of the document by the Declarant/Principal or by another person acting on behalf of the Declarant/Principal at the direction of the Declarant/Principal; that neither of us is appointed as attorney in fact by this document; that neither of us are health care providers who are presently treating the Declarant/Principal, or employees of such a health care provider. We further state that we are both at least 18 years of age, and that at least one of us is not related to the Declarant/Principal by blood, marriage or adoption.
____________________________________ |
____________________________________ |
Signature of First Witness |
Signature of Second Witness |
____________________________________ |
____________________________________ |
Type or Print Name of Witness |
Type or Print Name of Witness |
____________________________________ |
____________________________________ |
Street Address, City, State and Zip Code |
Street Address, City, State and Zip Code |
GENERAL INFORMATION REGARDING THIS DOCUMENT
1."Health care" means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition.
2.The terms "health care" and
3.The following individuals shall not be designated as the attorney in fact to make health care decisions under a durable power of attorney for health care:
a.A health care provider attending the principal on the date of execution.
b.An employee of such a health care provider unless the individual to be designated is related to the principal by blood, marriage, or adoption within the third degree of consanguinity.
4.The power of attorney for health care decisions or the declaration relating to use of
5.It is the responsibility of the principal/declarant to provide the attending health care provider with a copy of this document.
6.A declaration relating to use of
SUGGESTIONS AFTER FORM IS PROPERLY SIGNED, WITNESSED OR NOTARIZED
1.Place original in a safe place known and accessible to family members or close friends.
2.Provide a copy to your doctor.
3.Provide a copy(s) to family member(s).
4.Provide a copy to the designated attorney in fact (agent) and to alternate designated attorneys in fact (if any).
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO NOMINATED HEALTH CARE
Pursuant to the terms of a Durable Power of Attorney, Health Care Decisions, (or Combined Living Will and Medical Power of Attorney) (HCPOA) dated ______________________________, in which the undersigned
is the grantor, the power becomes effective in the event of my disability or incapacity.
AUTHORIZATION TO RELEASE INFORMATION:
I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company and the Medical Information Bureau, Inc., or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services, to give, disclose, and release to the person or persons designated in this document to act as my agent such of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition
(including all specially protected health information relating to each of the following conditions specifically authorized by me to be disclosed by marking the box with an "X" or a check mark:
Gsexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), and human immunodeficiency virus (HIV);
Gbehavioral and mental health; and
Galcohol, drug and other substance abuse)
________________________________________ |
______________________________ |
Signature of Principal |
Date |
relating to my ability to make health care decisions. The purpose of this request is to assist in determining whether the person designated to act as my agent should act as my agent. This authorization expires when I die or when revoked by me by a written revocation signed by me and delivered to the entity from which information is being requested prior to the time information is being requested.
I understand I can revoke this authorization by delivering a written statement of revocation to any entity I have authorized to give, disclose and release information. The revocation is effective only as to those entities to whom the written statement revocation is given and only after the time of delivery. I also understand that I have the right to inspect the disclosed information at any time. My treatment, payment, enrollment or eligibility for benefits with an entity that I have authorized to release information is not conditioned on my signing this authorization. I know that once the information I have authorized to be released is released it is subject to re- disclosure by the recipient and is no longer protected by the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated pursuant thereto, as amended from time to time.
THE AUTHORITY TO ACT AS PERSONAL REPRESENTATIVE
In addition to the other powers granted by the HCPOA, I grant to my agent the power and authority to serve as my personal representative for all purposes of the Health Insurance Portability and Accountability Act of 1996, as amended from time to time, and its regulations (HIPAA) during any time that my agent (hereinafter referred to in subsequent clauses of this paragraph as my "HIPAA personal representative") is exercising authority under this document.
Pursuant to HIPAA, I specifically authorize my HIPAA personal representative to request, receive and review any information regarding my physical or mental health, including without limitation all
Dated this _____day of ________________, _______.
_____________________________________
, Grantor