Louisiana Medical Power of Attorney Form

In the case of wanting to assign another person to act on your behalf in case you don’t have the clarity of mind to do so in the State of Louisianna, the following form has to be completed and submitted.

Extracted Text for Proper Search

LOUISIANA HEALTH CARE POWER OF ATTORNEY  
 
1.    I,   ,  hereby appoint:  
 	
        	
Name     
           	
 	
Home Address  
 
 
City, State  
   	
        
Home Telephone Number        
     
        
Work Telephone Number     
 
 
C ell

 Telephone Number  
 
 	
as my agent to make health- care decisions for me if I become unable to make 
my own health care decisions such as the following:  
 
          	  A. Grant, refuse, or withdraw consent on my behalf for any health care  
service, treatment or procedure, even though my death may ensue.  
 	
           	  B. Talk to health care personnel, get information, have access to medical  
records and sign forms necessary to carry out these decisions.  
 	
          	  C. Authorize my admission to or discharge from any hospital, nursing home,  
residential care, assisted living or similar facility or service.  
 	
          	  D. Contract on my behalf for any health- care related services or facility 
(without my agent incurring personal financial liability for such contracts) such as  
surgery, medical expenses and prescriptions.  
 	
          	  E. Make decisions regarding surgery, medical expenses and prescriptions.  
 
2.    If the person named as my agent is not available or is unable to act as my  
agent, I appoint the following person(s) to serve in the order listed below:  
 
A.   	
        	
Name               
 	
 	
Home Address  
 
 
C i	

ty, State  
 	
        
Home Telephone Number        
     
        	
Work Telephone Number     
 
 
Cel	

l Telephone Number

B. 
 	
        	
Name             
   
 	
 	
Home Address  
 
 
City, State  
 	
        	
Home Telephone Number        
     	
        	
Work Telephone Number     
 
 
Cell Telephone Number  	
 
3.   With this document, I intend to create a durable power of attorney for health 
care, which shall take effect upon and only during any period in which, in the opinion of  
my attending physician, I am unable to make or communicate a choice regarding a  
particular health- care decision. My agent shall make health- care decisions as I direct 
below or as I make known to him/her in some other way. If my agent is unable to 
determine the choice I would want to make, then my agent shall make a choice for me 
based upon what my agent believes to be in my best interest.  
 
4.    With this document, I authorize any person, organization, or entity  
involved with my health care to disclose and release to my agent any and all of my  
individually identifiable health information and medical records in accordance with  
HIPAA.  
 
5.  SPECIAL PROVISIONS AND LIMITATIONS. I do NOT want the following  
t reatments : 
 
 
______ ___	

_____________________________________________________________  	
 
6.   To the extent that I am permitted by law to do so, I herewith nominate my  
agent to serve as the curator of my person, and/or in any similar representative 
capacity. If I am not permitted by law to make a nomination, then I request in the 
strongest possible terms that any court consider this nomination.  
 
7.    No person who relies in good faith upon representations by my agent or  
alternate agent shall be liable to me, my estate, my heirs or assigns for recognizing the 
agent’s authority.  
 
8.    The powers delegated under this power of attorney are separable, so that the 
invalidity of one or more powers shall not affect any others.  
 
BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND  
EFFECT OF THIS DOCUMENT.

I sign my name to this form on	   	 	 	
          (Date) 
 
at:   	
(City, State) 
_______________________________________  
(Signature) 	
 
WITNESSES  
 
The person who signed or acknowledged this document is personally known to 
me and I believe him/her to be of sound mind.  
 
First Witness:  
Signature:       _________________________________________________  
 
Home Address:      
 
   
 
Prin	

t Name:              Date:  _____________	
 _ 
 
Second Witness:  
Signature:       _________________________________________________  
 
Home Address:      
 
   
 
Prin	

t Name:             Date: ______________ 
  NOT	

ARIZATION  
 
STATE OF    
PARISH OF    
 
I,	
 	 a Notary Public in and for the State and	 	
Parish aforesaid, do hereby certify that  	 	 who personally cam e and 
appeared before me as the Principal, and executed the foregoing Durable  Power of 
Attorney for Health -Care in said State and Parish, and acknowledged said  Durable 
Power of Attorney for Health- Care as the Principal’s voluntary act.  	
 
Witness my signature this ______ day of ____________________ , 20___. 
______________________________  
NOTARY PUBLIC