THE IOWA STATE BAR ASSOCIATION Official Form No. 121 FOR THE LEGAL EFFECT OF THE USE OF THIS FORM, CONSULT YOUR LAWYER DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS (Medical Power of Attorney) , I (the "Principal") hereby designate (Type or Print) First Name Last Name City (Type or Print) Street Address State Zip Code 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. NOTE: (The Principal does not have to give any specific instructions or statement of desires but may do so.) Insert here specific instructions or statement of desires of principal (if any). NOTE: (The Principal may designate one or more alternates as attorney in fact but does not have to.) If the person designated above is unable to serve, I designate (Type or Print) (Type or Print) First Name Last Name Street Address City State Zip Code to serve as my attorney in fact. Signed this day of , Signature of Principal (Person Granting the Power of Attorney) (Type or Print Name of Principal) Street Address City State Zip Code This Power of Attorney must be witnessed by two persons or notarized. STATE OF _______________________, COUNTY OF _______________________ This instrument was acknowledged before me on __________________________, by __________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________. ___________________________________ _______________________, Notary Public By signing this form I declare that I signed this form in the presence of the other witness and the Principal and I witnessed the signing by the Principal or other person acting on behalf of and at the Principal's direction. Signature of 1st Witness Signature of 2nd Witness (Type or Print Name of Witness) (Type or Print Name of Witness) Street Address Street Address City © The Iowa State Bar Association 2006 IOWADOCS® State Zip Code City State Zip Code 121 DURABLE POWER OF ATTORNEY FOR HEALTH CARE Revised January 2006 American LegalNet, Inc. www.FormsWorkflow.com AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO NOMINATED HEALTH CARE ATTORNEY-IN-FACT 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: ___sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), and human immunodeficiency virus (HIV); ___behavioral and mental health; and ___alcohol, drug and other substance abuse) 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 HIPAA-protected health information, medical and hospital records; to execute on my behalf any authorizations, releases, or other documents that may be required in order to obtain this information and to consent to the disclosure of this information. I further authorize my HIPAA personal representative to execute on my behalf any documents necessary or desirable to implement the health care decisions that my HIPAA personal representative is authorized to make under the HCPOA. Dated this _____day of ________________, _______. _______________________________ , Grantor American LegalNet, Inc. www.FormsWorkflow.com General Information on Durable Power of Attorney for Health Care A durable power of attorney for health care is subject to the provisions of Chapter 144B of the Code of Iowa and reference should be made to that chapter. The following is a summary of some of the provisions of Chapter 144B of the Code of lowa. 1. 2. "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. "Health care" does not include the provision of nutrition or hydration except when they are required to be provided parenterally or through intubation. The following individuals shall not be witnesses for 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 a health care provider attending the principal on the date of execution. c. The individual designated in the durable power of attorney for health care as the attorney in fact d. An individual who is less than eighteen years of age. 3. One of the witnesses shall be an individual who is not a relative of the principal by blood, marriage, or adoption within the third degree of consanguinity. 4. 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 a health care provider attending the principal on the date of execution unless the individual to 5. be designated is related to the principal by blood, marriage, or adoption within the third degree of consanguinity. Revocation. a. A durable power of attorney for health care may be revoked at any time and in any manner by which the b. c. d. e. f. g. 6. 7. principal is able to communicate the intent to revoke, without regard to mental or physical condition. Revocation may be made by notifying the attorney in fact orally or in writing. Revocation can also be made by notifying a health care provider orally or in writing while that provider is engaged in providing health care to the principal. A revocation is only effective as to a health care provider upon its communication to the provider by the principal or by another to whom the principal has communicated revocation. The health care provider is required to document the revocation in the treatment records of the principal. The principal is presumed to have the capacity to revoke a durable power of attorney for health care. Unless it provides otherwise, a valid durable power of attorney for health care revokes any prior durable power of attorney for health care. Prohibited Practices. a. A health care provider, health care service plan, insurer, self-insured employee welfare benefit plan, or nonprofit hospital plan shall not condition admission to a facility, or the providing of treatment, or insurance, on the requirement that an individual execute a durable power of attorney for health care. b. A policy of life insurance shall not be legally impaired or invalidated in any manner by the withholding or withdrawing of health care pursuant to the direction of an attorney in fact appointed pursuant to this Chapter. It is the responsibility of the principal to notify the health care provider (doctor) of the terms of the Durable Power of Attorney for Health Care. SUGGESTIONS AFTER FORM IS PROPERLY SIGNED, WITNESSED OR NOTARIZED 1. 2. Place original in a safe place known and accessible to family members or close friends. Provide a true copy to your doctor. 3. Provide a copy(s) to family member(s). 4. Provide a copy to designated attorney in fact (agent) and to alternate designated attorney(s) in fact (if any). American LegalNet, Inc. www.FormsWorkflow.com