The Iowa 123 form, recognized officially by The Iowa State Bar Association, serves two critical purposes: It is a Declaration Relating to Life-Sustaining Procedures (a Living Will) and a Durable Power of Attorney for Health Care Decisions (a Medical Power of Attorney). It allows individuals to specify their wishes regarding life-sustaining treatment and appoint someone to make healthcare decisions on their behalf if they are incapacitated. Ensuring your healthcare wishes are respected and designating someone you trust to make decisions for you are the form's primary goals. To secure your health care wishes for the future, consider filling out the Iowa 123 form by clicking the button below.
In today's rapidly evolving healthcare landscape, the importance of having legal documents in place that clearly articulate one's wishes for medical treatment in dire situations cannot be overstated. Among these essential documents, the Iowa 123 form plays a pivotal role, serving as both a declaration relating to life-sustaining procedures (commonly known as a Living Will) and a Durable Power of Attorney for Health Care Decisions (Medical Power of Attorney). Created by The Iowa State Bar Association, it is a comprehensive document designed to address the critical aspects of healthcare decision-making in the event an individual becomes incapacitated. It allows individuals to outline their preferences concerning life-sustaining treatments under terminal conditions or permanent unconsciousness and to appoint a trusted agent to make healthcare decisions on their behalf when they are unable to do so. Additionally, the form includes provisions for organ donation, explicitly aligning with Iowa's laws on anatomical gifts, and comprehensively covers the logistics of authorization for the release of protected health information to the nominated agent, ensuring that one's healthcare wishes are known, respected, and facilitated in accordance with their values and desires. The form's legal and procedural guidances—such as the revocation of prior durable powers of attorney for healthcare decisions, the designation of alternate agents, and the requirements for signing and witnessing—further ensure its effectiveness and enforceability. As such, the Iowa 123 form represents a critical tool in personal healthcare planning, embodying the legal articulation of one's preferences and authorizations for healthcare in circumstances where direct communication is no longer possible.
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 LIFE-SUSTAINING PROCEDURES
(Living Will)
AND
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
(Medical Power of Attorney)
I. DECLARATION RELATING TO LIFE-SUSTAINING PROCEDURES
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 life-sustaining procedures. If I am unable to participate in my health care decisions, I direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.
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 life-sustaining procedures, including a ventilator, for the sole purpose and time period required to complete the organ donation. Nothing in this paragraph shall be construed to expand or detract from the laws related to anatomical gifts as outlined in the Iowa Code, Chapter 142C. The purpose of this paragraph is to practically and medically make organ donation possible.
Signed this ____day of __________________, _____.
_____________________________________
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 LIFE-SUSTAINING PROCEDURES &
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
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. "Life-sustaining procedure" means any medical procedure, treatment, or intervention which utilizes mechanical or artificial means to sustain, restore, or supplement a spontaneous vital function, and when applied to a person in a terminal condition, would serve only to prolong the dying process. "Life sustaining procedure" does not include administration of medication or performance of any medical procedure deemed necessary to provide comfort care or to alleviate pain.
2.The terms "health care" and "life-sustaining procedure" include nutrition and hydration (food and water) only when provided parenterally or through intubation (intravenously or by feeding tube). Thus, this document authorizes withholding nutrition or hydration that is provided intravenously or by feeding tube. If this is not what you want, you should set forth your specific instructions in the space provided on page 1.
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 life-sustaining procedures may be revoked at any time and in any manner by which the principal/declarant is able to communicate the intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending health care provider upon its communication to the provider by the principal/declarant or by another to whom the principal/declarant has communicated the revocation.
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 life-sustaining procedures will be given effect only when the declarant's condition is determined to be terminal or the declarant is in a state of permanent unconsciousness, and the declarant is not able to make treatment decisions.
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 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:
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 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
After carefully selecting who will make health care decisions on your behalf if you become unable to do so, filling out the Iowa 123 form is the critical next step in documenting your wishes. This form serves as both your Living Will and Durable Power of Attorney for health care decisions, making clear your directives regarding life-sustaining procedures and appointing an agent to act on your behalf in medical matters when you can't. It's important to approach this task with precision to ensure that your health care preferences are honored and legally recognized. Following the guided steps below will help you accurately complete the Iowa 123 form.
Once the form is fully and accurately completed, it becomes a legal document. Ensure that copies are given to your health care provider, your appointed agent(s), and perhaps a trusted family member or friend. It's also advisable to review and, if necessary, update this document periodically, especially after major life events or changes in your health condition.
What is the purpose of the Iowa 123 Form?
The Iowa 123 Form serves dual purposes: it acts as a declaration relating to life-sustaining procedures, commonly referred to as a Living Will, and it also functions as a durable power of attorney for health care decisions. This document allows individuals to outline their preferences and instructions regarding medical treatment in situations where they are unable to make decisions for themselves due to severe health conditions. It also lets individuals appoint someone they trust as their agent to make health care decisions on their behalf under the same circumstances.
How does one revoke the Iowa 123 Form once it has been executed?
The Iowa 123 Form can be revoked at any time and in any manner by which the principal or declarant is capable of communicating their intention to revoke, irrespective of their mental or physical condition. This revocation becomes effective with regard to the attending health care provider when it is communicated to the provider by the principal or by someone else whom the principal has informed about the revocation. This ensures that individuals have the flexibility to change their mind regarding their health care directives.
Who is eligible to be designated as an attorney-in-fact for health care decisions in Iowa?
In Iowa, the individuals who cannot be designated as an attorney-in-fact for making health care decisions include the health care provider who is treating the principal on the date of the document’s execution and employees of the health care provider, unless they are related to the principal by blood, marriage, or adoption within the third degree of consanguinity. This restriction aims to prevent potential conflicts of interest and ensure that appointed agents have the principal’s best interests in mind.
What steps should be taken after signing the Iowa 123 Form?
After properly signing, witnessing, or having the document notarized, it’s recommended to store the original document in a safe place that is easily accessible to family members or close friends. Providing a copy to the principal’s doctor, family members, and the designated agent or alternate agent (if any) is also crucial. This ensures that the appointed health care decision-makers are aware of their responsibilities and the principal’s preferences are known and can be easily accessed when needed.
Filling out important legal forms like the Iowa State Bar Association's Official Form No. 123, which covers both the declaration relating to life-sustaining procedures (Living Will) and Durable Power of Attorney for Health Care decisions, requires careful attention to detail. Below, we outline common mistakes made during this process:
By avoiding these common errors, individuals can ensure that their health care preferences are known, respected, and followed in times when they cannot speak for themselves. It's not just about completing the form but doing so thoughtfully and correctly that matters most.
When preparing or executing the Iowa 123 form, which encompasses both a living will declaration and a durable power of attorney for health care decisions, individuals may need to consider several additional documents to ensure comprehensive planning and clarity regarding their wishes. These documents can provide further detail, appoint additional representatives, and ensure all aspects of one’s wishes are covered. Understanding each document and its purpose is crucial.
Together with the Iowa 123 form, these documents can provide a robust legal framework to guide individuals, their families, and their health care providers through difficult decisions about health care, finances, and estate management. Ensuring each document is properly completed, signed, and accessible to relevant parties can offer peace of mind and clarity during challenging times.
The Iowa 123 Form, as part of its comprehensive approach, resembles a Living Will in its first section, dedicated to the declaration relating to life-sustaining procedures. Like a traditional living will, this segment allows an individual to express their wishes regarding receiving or not receiving life-sustaining treatment if they become unable to communicate those decisions due to a severe medical condition. It serves the critical function of guiding healthcare providers and loved ones in making decisions that align with the declarant's values and preferences concerning end-of-life care.
Similar to a Durable Power of Attorney for Health Care, the second section of the Iowa 123 form allows the individual to appoint an agent to make healthcare decisions on their behalf if they are unable to do so. This document mirrors the essential purpose of a medical power of attorney by designating a trusted person to act as the individual's voice regarding health care decisions. This appointed agent is empowered to make a wide range of decisions, reflecting the individual's desires as specified in the document or made known through other means, ensuring their healthcare preferences are respected even when they can't communicate.
The Iowa 123 Form's provision for an alternate agent if the primary agent is unable to serve draws a parallel with the backup agent concept in standard power of attorney documents. This feature ensures that even if the initially chosen agent becomes unavailable or unwilling to act, another person, predetermined by the declarant, can step in to make important healthcare decisions. This foresight prevents a potential vacuum in decision-making authority and maintains continuity in the execution of the declarant’s healthcare preferences.
The optional section for additional provisions within the Iowa 123 Form shares similarities with addendums to advance directives or living wills, where individuals can specify particular wishes or instructions not covered in the standard document. This flexibility allows people to tailor the document to reflect their specific healthcare values, moral beliefs, and preferences in a more personalized way. It acknowledges the complexity and diversity of health care decisions, providing a space for individuals to articulate their unique wishes regarding organ donation, comfort care, and other important considerations.
Finally, the authorization for release of protected health information to the nominated health care attorney-in-fact is akin to a HIPAA release form. This provision permits designated agents to access the declarant's medical records, fostering informed decision-making based on the individual's medical history and current condition. By integrating this into the form, it facilitates seamless communication between healthcare providers and the appointed agent, ensuring decisions are made with a comprehensive understanding of the individual’s health status.
Filling out the Iowa 123 form, a crucial document that includes both a declaration relating to life-sustaining procedures and a durable power of attorney for health care decisions, requires careful attention to detail and clarity of intent. Here are essential do's and don'ts to help guide you through the process:
When diving into the topic of Iowa's official Form No. 123, it's easy to stumble upon a few widespread misconceptions. It's crucial to separate fact from fiction to ensure one's wishes regarding health care decisions are clearly understood and respected. Here are four common misunderstandings about this important document.
Understanding these misconceptions about the Iowa 123 form clears the way for more individuals to take control of their health care decisions confidently. Remember, this legal document is a living reflection of your wishes and can be adapted as your life evolves. Don't hesitate to consult an attorney if you need guidance on completing or updating this form to ensure it accurately represents your desires for medical care and decision-making.
When preparing and using the Iowa 123 Form, which combines a declaration relating to life-sustaining procedures (living will) and a durable power of attorney for health care decisions (medical power of attorney), it is vital to understand the key aspects and recommendations for its completion and implementation:
Understanding and adhering to the guidelines and requirements of the Iowa 123 Form ensures individuals can establish their health care wishes clearly and legally, providing peace of mind and control over their medical treatment preferences in situations where they may not be able to express their desires themselves.
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