Louisiana Medical Power of Attorney
This Medical Power of Attorney is created in accordance with Louisiana state law, specifically under Louisiana Revised Statutes, Title 28, Chapter 4. It allows you to appoint someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Date of Birth: ____________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City, State, Zip: ________________
- Phone Number: ____________________
Durable Power of Attorney:
This Medical Power of Attorney shall remain in effect even if I become incapacitated. I grant my agent the authority to make all healthcare decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Making end-of-life decisions.
Limitations:
My agent shall not have the authority to make decisions regarding:
- Any treatment that is not in accordance with my wishes.
- Any decisions that would lead to my death, unless I am in a terminal condition.
Signatures:
By signing below, I confirm that I am of sound mind and voluntarily appoint the above-named agent to act on my behalf regarding medical decisions.
Principal Signature: ___________________________
Date: ______________________________________
Witness Signature: ___________________________
Date: ______________________________________
Witness Signature: ___________________________
Date: ______________________________________
Notarization:
State of Louisiana
Parish of ___________________________
Subscribed and sworn to before me this ____ day of __________, 20__.
Notary Public: ___________________________
My Commission Expires: ________________