MAKE YOUR FREE Iowa Medical Power of Attorney

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

. DESIGNATION OF AGENT. I, , hereby designate:

as my Attorney-in-Fact (my Agent) and give to my Agent the power to make health care decisions for me.

NOTICE: Do not name an Attorney-in-Fact without his or her permission. The Attorney-in-Fact may NOT be your Health Care Professional or Provider attending you on the date you sign this instrument, or an employee of such Health Care Professional or Provider. The Attorney-in-Fact does not need to be a lawyer.

. GENERAL STATEMENT OF AUTHORITY GRANTED. This power exists only when I am unable, in the judgment of my attending physician, to make health care decisions for myself. 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 law 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 the provision 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. My agent has the right to examine my medical records and to consent to disclosure of such records.

I hereby revoke all prior Durable Powers of Attorney for Health Care.

. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO NOMINATED HEALTH CARE ATTORNEY-IN-FACT. Pursuant to the terms of this Durable Power of Attorney for Health Care, I authorize any physician, health care professional, dentist, health plan, health plan provider, hospital, clinic, laboratory, pharmacy, or other covered health care provider, and insurance company and the Medical Information Bureau (MIB) Group, 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

relating to my ability to make health care decisions. The purpose of this request is to assist in determining whether the person designated 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 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 conditional on my signing this authorization. I know that once the information I have authorized to be released is released, it is subject to redisclosure 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 ("HIPAA").

. AUTHORITY TO ACT AS PERSONAL REPRESENTATIVE. In addition to the other powers granted by this Durable Power of Attorney for Health Care, I grant to my Agent the power and authority to serve as my personal representative for all purposes under HIPAA during any time that my Agent is exercising authority under this document.

Pursuant to HIPAA, I specifically authorize my Agent 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 Agent to execute on my behalf any documents necessary or desirable to implement the health care decisions that my Agent is authorized to make under this Durable Power of Attorney for Health Care.

. GENERAL PROVISIONS.

1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.

2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.

SIGNATURE MUST BE EITHER NOTARIZED OR WITNESSED

BY TWO PERSONS.

I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.

Signed on _____ day of _______________, _____.