Durable Power of Attorney for Health Care Will to Live Form - Iowa

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Iowa Durable Power of Attorney for Health Care
Will to Live Form
I, (your name)________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
hereby designate:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________
as my attorney-in-fact (my “agent”) 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.
In the event the person I designate above is unable, unwilling or unavailable, or ineligible to act
as my health care agent, I hereby designate the following person(s) as my attorney-in-fact (my
agent) and give to my agent the power to make health care decisions for me (each to act alone
and serve successively, in the order named):
A. First Successor Agent
(successor agent’s name)_________________________________________________________
(successor agent’s address)________________________________________________________
_____________________________________________________________________________
(successor agent’s phone number)__________________________________________________
B. Second Successor Agent
(second successor agent’s name)___________________________________________________
(second successor agent’s address)__________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
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 the provisions of 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.
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