The Iowa 123 form is a crucial legal document that combines a Living Will and a Durable Power of Attorney for Health Care Decisions. This form allows individuals to express their wishes regarding life-sustaining procedures and designate someone to make health care decisions on their behalf if they become unable to do so. It's essential to complete this form to ensure your health care preferences are honored—take action by filling it out today!
The Iowa 123 form is a crucial document designed to address health care decisions in the event of a person's incapacity. It combines two significant components: the Declaration Relating to Life-Sustaining Procedures, commonly known as a living will, and the Durable Power of Attorney for Health Care Decisions. The living will allows individuals to express their wishes regarding life-sustaining treatments in situations where they face an incurable condition or are in a state of permanent unconsciousness. This declaration ensures that medical professionals understand the individual's desire to avoid prolonged suffering through unnecessary medical interventions. The Durable Power of Attorney section enables individuals to appoint an agent who will make health care decisions on their behalf when they are unable to do so. This agent is tasked with acting in accordance with the principal's stated desires, ensuring that personal values and preferences guide medical care. The Iowa 123 form also provides optional sections for additional provisions and designates an alternate agent if the primary agent is unable to serve. Proper execution of this form requires notarization or witness signatures, making it essential for individuals to understand the implications and requirements of the document.
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
Filling out the Iowa 123 form is a straightforward process that allows you to express your wishes regarding life-sustaining procedures and appoint someone to make health care decisions on your behalf if you are unable to do so. Follow the steps below to complete the form accurately.
The Iowa 123 form is an official document that combines a Living Will and a Durable Power of Attorney for Health Care Decisions. It allows individuals to express their wishes regarding life-sustaining procedures and designate an agent to make health care decisions on their behalf if they become unable to do so. This form is crucial for ensuring that one’s health care preferences are honored, particularly in critical situations.
Anyone who wants to make their health care preferences known should consider completing the Iowa 123 form. This includes individuals with chronic illnesses, those approaching advanced age, or anyone who wishes to take proactive steps in managing their health care. It is particularly important for those who may face situations where they cannot communicate their wishes due to medical conditions.
This section allows individuals to specify their desires regarding life-sustaining procedures in the event of an incurable or irreversible condition. If a person is diagnosed with such a condition and cannot communicate, they can direct their attending physician to withhold or withdraw life-sustaining measures that merely prolong the dying process. It is important to note that this declaration can include specific instructions in the "Additional Provisions" section.
This part of the form designates an agent who will make health care decisions on behalf of the individual if they are unable to do so. The agent must act according to the wishes expressed in the form or any other known preferences of the individual. The agent's authority includes consenting to, refusing, or withdrawing consent for any medical treatment, ensuring that the individual’s health care aligns with their values and desires.
Yes, individuals can revoke the Iowa 123 form at any time, as long as they are able to communicate their intent. This revocation can be made in any manner that clearly indicates the desire to cancel the document. It is advisable to communicate this revocation to the attending health care provider to ensure that they are aware of the change.
The Iowa 123 form allows individuals to designate an alternate agent in case the primary agent is unable to fulfill their duties. This ensures that there is always someone available to make health care decisions in accordance with the individual's wishes. It is wise to choose someone trustworthy and capable of handling such responsibilities.
Yes, the Iowa 123 form must be signed or acknowledged before a notary public or two witnesses. This requirement helps ensure the authenticity of the document and that the individual signing it is doing so voluntarily and understands its implications. Witnesses must meet specific criteria, such as being at least 18 years old and not being related to the individual.
After signing and witnessing the form, it is essential to take several steps:
These actions help ensure that your health care wishes are known and can be honored when necessary.
If you have questions or need help completing the Iowa 123 form, it is highly recommended to consult an attorney. Legal professionals can provide guidance tailored to your specific situation and ensure that your document accurately reflects your wishes.
Incomplete Information: Many individuals fail to provide all required personal details, such as their full name, date of birth, and contact information for both themselves and their designated agent. This omission can render the form invalid.
Not Following Signature Requirements: Some people neglect to sign the document in the presence of a notary public or witnesses, as stipulated. Without proper signatures, the document may not be legally recognized.
Ignoring Additional Provisions: Individuals often overlook the section for additional instructions or desires. Failing to specify personal wishes can lead to decisions that do not align with their preferences.
Designating Ineligible Agents: It is common for people to mistakenly appoint health care providers or their employees as agents. This is not allowed under Iowa law, and such designations can invalidate the document.
The Iowa 123 form is a crucial document for individuals making decisions about their health care and life-sustaining procedures. It is often accompanied by several other forms and documents that further clarify and support the wishes of the individual. Below is a list of these commonly used documents.
Each of these documents plays a significant role in ensuring that an individual's health care preferences are respected and followed. It is important to complete and maintain these documents properly to avoid complications in critical situations.
The Iowa 123 form shares similarities with the Advance Directive, a document that outlines an individual's preferences regarding medical treatment in situations where they cannot communicate their wishes. Like the Iowa 123 form, an Advance Directive allows individuals to specify their choices about life-sustaining treatments and appoint a surrogate decision-maker. This document ensures that a person's healthcare preferences are respected, mirroring the intention behind the Iowa form to provide clarity and guidance in critical medical situations.
Another document akin to the Iowa 123 form is the Do Not Resuscitate (DNR) order. A DNR order specifically instructs healthcare providers not to perform CPR or other life-saving measures in the event of cardiac arrest. While the Iowa 123 form addresses broader healthcare decisions and life-sustaining procedures, the DNR focuses solely on resuscitation efforts. Both documents emphasize patient autonomy and the importance of aligning medical interventions with an individual's wishes, especially in end-of-life scenarios.
The Health Care Proxy is yet another document that parallels the Iowa 123 form. This legal instrument designates a specific person to make healthcare decisions on behalf of an individual if they become incapacitated. Similar to the Durable Power of Attorney for Health Care Decisions found in the Iowa 123 form, a Health Care Proxy ensures that someone trusted can advocate for a person's medical preferences. Both documents reinforce the significance of having a designated advocate during critical health crises.
The Five Wishes document also bears resemblance to the Iowa 123 form. It combines elements of a living will and a durable power of attorney, allowing individuals to express their healthcare preferences in a more comprehensive manner. Five Wishes covers not only medical treatment choices but also personal, emotional, and spiritual preferences at the end of life. Like the Iowa form, it aims to ensure that a person's values and desires are honored in healthcare decisions.
Similar to the Iowa 123 form is the Living Will, which specifically addresses an individual's preferences regarding life-sustaining treatments in situations of terminal illness or irreversible conditions. While the Iowa form encompasses both a living will and a durable power of attorney, the Living Will focuses primarily on the types of medical interventions a person wishes to receive or refuse. Both documents serve the vital purpose of communicating an individual's wishes to healthcare providers.
The Medical Power of Attorney is another document that closely aligns with the Durable Power of Attorney for Health Care Decisions in the Iowa 123 form. This legal document empowers a designated individual to make healthcare decisions on behalf of someone who is unable to do so. Both forms emphasize the importance of appointing a trusted agent to ensure that an individual’s healthcare preferences are honored, particularly in times of incapacity.
The Authorization for Release of Medical Records is also similar to aspects of the Iowa 123 form. This document allows individuals to grant permission for healthcare providers to share their medical information with designated persons. While the Iowa form focuses on decision-making authority, the authorization ensures that the appointed agent can access necessary medical information to make informed choices. Both documents highlight the importance of communication and trust in the healthcare decision-making process.
Finally, the Organ Donation Consent form shares similarities with the Iowa 123 form, particularly regarding provisions for organ donation in the context of life-sustaining procedures. While the Iowa form includes a section addressing organ donation, a standalone Organ Donation Consent form explicitly outlines an individual's wishes regarding organ donation. Both documents emphasize the importance of ensuring that a person's desires regarding organ donation are respected and acted upon, further reinforcing the principle of patient autonomy.
When filling out the Iowa 123 form, it’s important to ensure accuracy and clarity. Here’s a list of things you should and shouldn’t do:
This form is relevant for anyone who wants to make health care decisions in advance, regardless of age. It’s a proactive way to ensure your wishes are known.
The Iowa 123 form does not deny treatment. It only specifies your wishes regarding life-sustaining procedures in certain situations.
You can revoke or change your Iowa 123 form at any time as long as you can communicate your intent.
While consulting a lawyer can be helpful, you can complete the Iowa 123 form on your own. Just ensure it is signed and witnessed properly.
Without the Iowa 123 form, your family may not know your specific wishes regarding health care decisions. It’s important to document them clearly.
The Iowa 123 form covers both life-sustaining procedures and health care decisions, not just organ donation.
In fact, witnesses should not be related to you by blood, marriage, or adoption. This helps ensure impartiality.
There are restrictions. Health care providers currently treating you cannot serve as your agent.
The form only takes effect when you are unable to make your own health care decisions, as determined by your physician.
It’s essential to provide copies to your health care provider and family members so they are aware of your wishes.
Key Takeaways for Filling Out and Using the Iowa 123 Form: