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Louisiana Medical Power of Attorney Form

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Louisiana Medical Power of Attorney Form

Updated August 08, 2023

A Louisiana medical power of attorney form functions as a written tool where a principal will grant the power of his or her authority to a trusted friend or relative over principal health care decisions. This is used if and when the principal ends up in a situation where he or she is not able to make or communicate health care or medical decisions. It is important to have the form in place in the event of an accident, scheduled surgery, or when faced with a terminal illness.

Living Will – Used to create a mandate on whether the patient would like to receive artificial feeding and/or breathing if they are in a vegetative state with no known cure.

How to Write

Download: PDF, MS Word, OpenDocument

1 – Open The Power Form Required To Deliver Authority In A Principal’s Health Care

You may open the Health Authority Form by clicking the button labeled “PDF,” “Word,” or “ODT.” Ideally, you should open a form that you have compatible software for but, if such software is lacking, most up-to-date browsers are form-friendly with PDF files.

2 – The Principal Will Need To Name The Health Care Agent In A Declaration

The first line in this paperwork will require the First, Middle, and Last Name of the Principal designating an individual to make Health Care Decisions in his or her name through this paperwork. The next blank line needs the First, Middle, and Last Name of the Health Care Agent being assigned the Authority to make Health Care Decisions on behalf of the Principal. The next four lines have been provided to document the Contact Information of the Health Care Agent. Use them to enter the Street Address, City, State, and Zip Code where the Health Care Agent lives, as well as the Home and Work Telephone Number where the Health Care Agent may be reached.

3 – A Description Of The Health Care Agent’s Powers

Next, there will be a list of lettered statements. Each statement will describe what the Health Care Agent will be able to do regarding the Principal’s Health Care as a result of this completed form. Any part (or the entirety) of these statements may be crossed out or deleted if the Principal wishes to withdraw a Power defined. It is strongly encouraged the Principal consult with a Health Care Professional and/or an attorney before striking out any of these statements.

The Principal will assign the Health Care Agent with the responsibility and Authority to make decisions regarding the Principal’s treatment even if it results in his or her death in Statement A. If this is not a function that should be assigned to the Health Care Agent, this statement should be crossed out. Statement B assigns the Health Care Agent with the ability and authority to consult with Health Care Professionals regarding the Principal’s treatment and to sign any necessary (for treatment) form. This statement may be crossed out or deleted if the Principal does not wish to approve the Health Care Agent’s use of such Authority. If the Agent is expected to authorize the Principal’s Admission or Discharge from any Health Care Institution then Statement C should be left unaltered, otherwise, it should be crossed out to prevent the Health Care Agent from assuming these Powers. Statement D will allow the Health Care Agent to contract Health Care Services, including surgery and prescriptions, without being held liable. This Power may be withdrawn from this document and restricted from the Health Care Agent if this statement is crossed out. Statement E empowers the Health Care agent to make decisions regarding the Principal’s surgeries, medical expenses, and prescriptions. This may be removed as a granted Power once it is crossed out or deleted.

4 – The Successor Agent Option

The Principal issuing this form may wish some added security in terms of making sure he or she will always have a Health Care Agent in place. If so, then Item 2 should be completed. Here, you will be able to document up to two additional Health Care Agent who will assume Power successively, when the current Health Care Agent cannot, will not, or is unable to carry out his or her function. Three sets of blank lines, labeled “A,” “B,” and “C” have been provided so that two individuals may be documented. Each Health Care Agent will require his or her Name, Home Address, City/State, Home Telephone Number, and Work Telephone Number recorded in one set of lines to be declared a Health Care Agent in reserve or Successor Agent.

5 – Required Language To Provide Authority

Item 3 will name this document as a Durable Power of Attorney to start upon the diagnosis that the Principal is unable to make his or her own Health Care Decisions. Furthermore, it will empower the Health Care Agent with the ability to make treatment choices regarding a subject or treatment he or she has not discussed with the Principal. Any part of this statement may be crossed out or altered, however, it is strongly recommended to consult an appropriate professional before doing so. Item 4 presents the wording necessary for the Health Care Agent to gain access to the Principal’s information and Medical Records under the Health Insurance Portability and Accountability Act (1996). The Health Care Agent may be restricted from such Powers by crossing out this statement. Item 5 will give the Principal a defined area where he or she may freely discuss and name all the treatments that should not be applied according to the circumstances he or she described. This may be continued on an attachment if there is not enough room If Item 6 is not crossed out or deleted, it will provide the wording required to name the Health Care Agent as the Curator or similar role of the Principal’s person. In addition, if the courts decide that one should be placed by the court, this statement will strongly nominate the Health Care Agent for the courts’ consideration. Statement Number 7 releases anyone who recognizes the Health Care Agent’s Authority described in this document from being held liable for doing so by the Principal or the Principal’s Estate. This statement may be left out of the Principal’s granted Authority by simply crossing it out. The last statement holds that each Power granted in this document should be recognized as a separate Power from the other. If this is struck out, the Powers in this document will be taken as a whole.


6 – Proof Of Both the Principal’s Intent And The Agent’s Acceptance Must Be Supplied

The end of this document will require the Day, Month, and Year of the Principal’s Signature Date on the first three blank lines in the statement beginning with the words “I sign my name…”

The last blank line of this statement must have the Address where this document is being signed.

The Principal must sign his or her Name on the blank line labeled “Principal’s Signature.”

The “Acceptance of Agent” paragraph will have three requirements. The Principal’s Name must be presented on the blank line after the words “…Agent for,” the Acceptance statement must be read by each Health Care Agent, and that each Health Care Agent signs his or her Name on one of the blank lines labeled “Agent.”

7 – The Signing Of This Form Will Need Some Verification

Two witnesses will need to observe this signing. Each one must read the “Witnesses” section, then sign his or her Name on the blank line labeled “Witness.”

The last page, “Notarization,” will need to be filled out and stamped by the Notary Public serving this document’s signing. This entity may provide some additional instructions which should be followed by all the signature parties.

Once the document is properly executed, make sure to make copies for your agent and backup agent and your medical providers.