Louisiana Medical Power of Attorney Form

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LOUISIANA HEALTH CARE POWER OF ATTORNEY
1. I, , hereby appoint:

Name

Home Address
City, State

Home Telephone Number

Work Telephone Number
Cell 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
City, State

Home Telephone Number

Work Telephone Number
Cell Telephone NumberB.

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
treatments:
______________________________________________________________________
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:
Print Name: Date: ______________
Second Witness:
Signature: _________________________________________________
Home Address:
Print Name: Date: ______________
NOTARIZATION
STATE OF
PARISH OF
I, a Notary Public in and for the State and
Parish aforesaid, do hereby certify that who personally came 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