144B.5  Durable power of attorney for health care — form.
  1.  A durable power of attorney for health care executed pursuant to this chapter may, but need not, be in the following form:
  I hereby designate ................................ 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 law of this state, 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.
  2.  In addition to the foregoing, the principal may provide specific instructions in the document conferring the durable power of attorney for health care, consistent with the provisions of this chapter.
  3.  The principal may include a statement indicating that the designated attorney in fact has been notified of and consented to the designation.
  4.  A durable power of attorney for health care may designate one or more alternative attorneys in fact.
  5.  A durable power of attorney for health care may include a declaration under chapter 144C that names a designee and alternate designees who may be different persons than the attorney in fact or alternate attorneys in fact who are designated in the durable power of attorney for health care.
91 Acts, ch 140, §5; 2008 Acts, ch 1051, §5, 22