Louisiana Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants a trusted person the authority to make healthcare decisions on your behalf, in accordance with the laws of the State of Louisiana, specifically under the Louisiana Revised Statutes (L.R.S.) Title 40:1299.58.1 et seq., known as the Louisiana Advance Directive Act. This document only becomes effective when you, the principal, are unable to make or communicate your healthcare decisions.
Principal Information
Name: ___________________________________________
Address: _________________________________________
City, State, Zip: _________________________________
Date of Birth: ____________________________________
Social Security Number: __________________________
Agent Information
Name: ___________________________________________
Relationship to Principal: _________________________
Primary Phone Number: ____________________________
Alternate Phone Number: __________________________
Email Address: ___________________________________
In accordance with Louisiana law, I hereby appoint the above-named person as my agent to make healthcare decisions on my behalf, including but not limited to:
- Consenting or refusing consent to any medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Selecting or discharging healthcare providers and institutions.
- Approving or disapproving diagnostic tests, surgical procedures, and programs of medication.
- Directing the provision, withholding, or withdrawal of life-sustaining treatment.
- Having access to medical records and information to the same extent that I am entitled, as allowed by law, to make informed decisions regarding my care.
This document represents my express wishes and replaces any prior medical power of attorney documents I may have executed. I understand that I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance upon it. To revoke, a written notice must be provided to the appointed agent.
Additional Provisions
________________________________________________________________
________________________________________________________________
Principal Signature
Date: _____________________________
Signature: _________________________
Agent Signature
I affirm that I am personally acquainted with the principal and that I am willing to act as their healthcare agent, in accordance with the terms of this Louisiana Medical Power of Attorney.
Date: _____________________________
Signature: _________________________
Witness Statement
The principal and agent's signatures were made in my presence, and I am not named as an agent or successor agent in this document.
Date: _____________________________
Signature of Witness #1: _______________
Printed Name: ________________________
Signature of Witness #2: _______________
Printed Name: ________________________
This document was prepared in accordance with the laws of the State of Louisiana and represents the principal's directions and wishes regarding their healthcare. It is recommended that you consult with a healthcare professional or attorney if you have any questions about this form.