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Louisiana Health Care Power of Attorney Form

The Louisiana health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Louisiana Health Care Power of Attorney Form
Louisiana Health Care Power of Attorney Form
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
Ci
ty, State
Home Telephone Number
Work Telephone Number
Cell Telephone Number
Louisiana Health Care Power of Attorney Form
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