The Iowa 123 form, officially known as the Official Form No. 123 by The Iowa State Bar Association, serves a dual purpose: It acts as a Declaration Relating to Life-Sustaining Procedures, commonly referred to as a Living Will, and also functions as a Durable Power of Attorney for Health Care Decisions. This document allows individuals to outline their preferences for medical treatment in situations where they are unable to make decisions for themselves and appoint someone to make health care decisions on their behalf. Taking the step to complete this form ensures your wishes are respected and provides guidance to loved ones during difficult times. Interested in ensuring your healthcare preferences are honored? Click the button below to get started on filling out the Iowa 123 form.
Navigating through personal and sensitive decisions regarding health care, especially those pertaining to life-sustaining procedures, can be daunting. This is where the Iowa 123 form comes into play, serving as a beacon of clarity and direction for individuals in the face of incapacitating health conditions. Officially provided by The Iowa State Bar Association, this essential legal document combines a Declaration Relating to Life-Sustaining Procedures, commonly known as a Living Will, with a Durable Power of Attorney for Health Care Decisions. It enables individuals to assert their wishes regarding medical treatments that prolong life in situations where recovery is not expected, and to designate a trusted person to make health care decisions on their behalf if they become unable to do so. Additionally, the form allows for the designation of an alternate agent, offers space for additional provisions, and addresses organ donation in specific circumstances. Importantly, the form outlines instructions for its execution, highlighting the necessity of signing or acknowledging it before a notary public or two witnesses, thereby ensuring its legal standing. Reflecting thoughtful consideration of an individual's autonomy and desire for dignity at life’s end, the Iowa 123 form is a powerful tool in planning for future health care needs, specifying that it should only come into effect under certain terminal conditions or states of permanent unconsciousness. Moreover, by providing the opportunity to revoke prior durable powers of attorney for health care decisions, it underscores the dynamic nature of personal health care planning. The form also sensitively handles the distribution of information and advises on the storage and sharing of the signed document, ensuring that one's wishes are known and respected by family members, health care providers, and designated agents alike.
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 significant step in planning for future healthcare decisions. This document allows you to express your wishes about medical treatment in situations where you may not be able to make decisions yourself. It combines a living will declaration and a durable power of attorney for health care decisions. Carefully completing this form ensures your healthcare preferences are known and appoints someone you trust to make decisions on your behalf if necessary. Below are step-by-step instructions for completing the form accurately.
After completing the form, it is crucial to discuss your decisions with the person you have designated as your attorney in fact, your family, close friends, and your primary healthcare provider to ensure everyone understands your wishes. Making copies to distribute to these parties and keeping the original document in a safe but accessible place are recommended steps to ensure your healthcare preferences are respected.
What is an Iowa 123 form?
The Iowa 123 form is an official document provided by The Iowa State Bar Association, encompassing both a Declaration Relating to Life-Sustaining Procedures (Living Will) and a Durable Power of Attorney for Health Care Decisions. This document allows individuals to outline their health care preferences, including end-of-life decisions and the appointment of an agent to make health care decisions if they are unable to do so.
When does the power of attorney for health care decisions come into effect?
It becomes active only when, according to the attending physician, the individual is unable to make their own health care decisions. This determination hinges on the individual's capability to understand and communicate health care decisions.
Can I specify my wishes regarding life-sustaining procedures in the Iowa 123 form?
Yes, the form allows you to clearly state your desires about the use of life-sustaining procedures should you have an incurable or irreversible condition leading to death within a relatively short time or result in a state of permanent unconsciousness from which recovery is not expected. You can also articulate any specific instructions or desires in the "Additional Provisions" section.
Who can be designated as an agent in the Durable Power of Attorney for Health Care?
Anyone you trust to make health care decisions on your behalf can be designated as an agent, except for your health care providers or their employees, unless they are related to you by blood, marriage, or adoption. This ensures unbiased decision-making in accordance with your wishes.
Can I appoint an alternate agent?
Yes, the form provides an option to designate an alternate agent who will serve in the capacity if the primary agent is unable, unwilling, or unavailable to act as your health care decision-maker.
How can I revoke the Iowa 123 form?
You can revoke the document at any time in any manner that effectively communicates your intent to revoke, irrespective of your mental or physical condition. It's crucial that the revocation is communicated to your attending health care provider for it to be effective.
Is notarization or witnessing required for the form to be valid?
Yes, the document must be either notarized or signed in the presence of two witnesses to be legally valid. The witnesses must be adults, and at least one of them should not be related to you or appointed as your agent in the document, ensuring impartiality in the witnessing process.
Should I share copies of the completed form with anyone?
After properly completing the form, it's recommended to place the original in a safe and accessible location. Copies should be provided to your doctor, family members, and anyone designated as an agent or alternate agent within the document. This ensures that all relevant parties are informed about your health care preferences.
What happens if I change my mind about my health care agent or wishes?
You have the right to update or change your health care agent or your health care wishes at any time. It's important to complete a new form reflecting these changes and inform all parties involved, including providing updated copies to health care providers and revoking previous versions of the form to avoid confusion.
Completing official forms can sometimes be daunting, and it's easy to make mistakes without realizing it. When it comes to the Iowa 123 Form, which includes both a Living Will declaration and a Durable Power of Attorney for Health Care Decisions, being accurate and thorough is crucial. Here's an outline of common errors people tend to make when filling out this document:
These mistakes are common but entirely avoidable with careful attention and perhaps guidance from a legal professional. The Iowa 123 Form is a powerful document that communicates your health care preferences when you cannot, ensuring your wishes are respected and followed.
When preparing for future medical decisions or setting your affairs in order, it's crucial to complement the Iowa Form 123 (Living Will and Durable Power of Attorney for Health Care Decisions) with other essential legal documents. Each document has its own significance and role in ensuring your wishes are respected and your matters are handled according to your expectations.
Combining the Iowa Form 123 with these documents can provide a comprehensive approach to estate and health care planning. This preparedness ensures that your health care wishes are known and respected and that your financial and personal matters are handled according to your directives. It is advisable to consult with legal professionals when preparing these documents to ensure they meet your specific needs and comply with Iowa law.
The Iowa 123 form, a blend of a living will and a durable power of attorney for health care decisions, shares similarities with the Advance Healthcare Directive found in various states. Both documents allow individuals to outline their preferences for medical treatment should they become unable to make decisions for themselves. The Advance Healthcare Directive typically includes instructions regarding life-sustaining treatment and may also appoint a healthcare agent, mirroring the dual functionality of the Iowa 123 form. Additionally, these documents often include provisions for organ donation, reflecting a comprehensive approach to end-of-life planning.
A Medical Power of Attorney is closely related to the portion of the Iowa 123 form that appoints a healthcare agent. This document exclusively deals with the delegation of healthcare decision-making authority to an appointed agent when the principal cannot make those decisions. It shares the core concept with the Iowa 123 form but is solely focused on the appointment of an agent without addressing living will aspects, such as specific preferences for life-sustaining treatments.
The Living Will, distinct yet similar to part of the Iowa 123 form, specifies an individual's preferences for end-of-life care, particularly concerning life-sustaining treatments. While the Iowa 123 form includes both a living will and a healthcare power of attorney, a standalone living will focuses only on the declaration regarding life-sustaining procedures without appointing a healthcare agent.
The Do Not Resuscitate (DNR) Order, although more specific than the broad scope of the Iowa 123 form, shares its concern with decisions made at the end of life. A DNR is a medical order indicating that an individual does not want CPR or other life-sustaining measures if their heart stops or they stop breathing. This order aligns with the living will component of the Iowa 123 form, which may include directives against prolonging life in certain dire medical situations.
The POLST (Physician Orders for Life-Sustaining Treatment) form is another medical order like the DNR but covers a broader range of treatments beyond CPR. The POLST is designed to ensure that seriously ill or frail patients' treatment preferences are honored by healthcare providers. Its detail and medical order status offer a complementary perspective to the more general directives included in the Iowa 123 form’s living will section.
A Healthcare Proxy is similar to the durable power of attorney for health care decisions component of the Iowa 123 form. It allows an individual to appoint a proxy, or agent, to make healthcare decisions on their behalf if they are incapable of doing so. The primary focus is on the delegation of decision-making authority, akin to the Medical Power of Attorney, highlighting the importance of choosing a trusted individual to represent the patient's healthcare interests.
The HIPAA Authorization Form, while not a directive on healthcare decisions per se, is related to the Iowa 123 form in its consideration of the privacy and disclosure of health information. It permits healthcare providers to disclose an individual's health information to specified persons or entities, potentially including the healthcare agent designated in the Iowa 123 form. This form is essential for implementing healthcare decisions since it ensures the flow of information needed by the appointed agent to make informed decisions.
An Organ Donation Registration form, which might be slightly addressed within the Iowa 123 form's optional provisions for organ donation in the event of death, explicitly allows individuals to enroll in a state's organ donor registry. Though it serves a more targeted purpose, it shares the Iowa 123 form's concern with making one's wishes known regarding the use of their body after death for the purpose of organ donation.
A Five Wishes Document goes beyond traditional healthcare directives by addressing personal, emotional, and spiritual needs alongside medical wishes. While it serves a similar purpose to the Iowa 123 form in guiding end-of-life care and decision-making, Five Wishes places greater emphasis on the holistic aspects of care preferences, making it a more expansive approach to living wills and healthcare powers of attorney.
Finally, a Mental Health Advance Directive, distinct but related in its intention to pre-plan healthcare decisions, allows individuals to outline their preferences for mental health treatment, including medication, hospitalization, and therapeutic interventions. While the Iowa 123 form focuses more on physical health decisions, a Mental Health Advance Directive complements it by providing a means to express wishes regarding mental health care, underscoring the importance of planning for all aspects of health and wellbeing.
When you're filling out the Iowa 123 form, it's crucial to get everything right. Here are some key dos and don'ts to guide you through the process:
Do's:
Don'ts:
When dealing with the intricacies of legal and medical forms, misunderstandings abound. The Iowa 123 form, which encompasses both the Declaration Relating to Life-Sustaining Procedures and the Durable Power of Attorney for Health Care Decisions, is no exception. Let's clarify some common misconceptions to ensure individuals are fully informed when completing this important document.
Clarifying these misconceptions ensures that individuals preparing the Iowa 123 form can make informed decisions that truly reflect their health care preferences.
When filling out and using the Iowa 123 Form, which combines a declaration related to life-sustaining procedures (Living Will) and a Durable Power of Attorney for Health Care Decisions, it is important to keep in mind several key takeaways:
Note: The individual is encouraged to consult with an attorney if they have any questions or need assistance with filling out the form to ensure their wishes are clearly and legally documented.
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