Fillable Printable Health Care Power of Attorney Form - Louisiana

Health Care Power of Attorney Form - Louisiana

LOUISIANA HEALTH CARE POWER OF AT TORNEY

1. I, , her eby appoint :

Name

Home Address

City, State

Home T el ephone Number

Work Telephone Number

Cell Telephone Number

as my agent t o make health-car e decisions for m e if I become unable to make

my own health care decisions such as the followin g:

A. Grant, refuse, or withdraw consent on my behalf for any health care

service, t r eatm ent or pr ocedure, even though my death may ensue.

B. Talk to health care per sonnel, get inf or mation, have access to m edical

records and sign f or ms neces sary to carry out these decisions.

C. Authorize my admission to or dischar ge f rom any hospital, nursing ho me,

residential care, assisted living or sim ilar f ac il it y or s er v ice.

D. Contract on my behalf for any health-care r elat ed services or facility

(without my agent incur ring personal financial liability f or such c ont ract s ) s uch as

surgery, medica l expenses and prescr ipt ions.

E. Make decisions regarding surgery, medical expenses and prescript ions.

2. If the person nam ed as my agent is not available or is unable to act as my

agent, I appoint the f ollowing person(s ) to serve in the order listed below:

Name

Home Address

ty, State

Home T el ephone Number

Work Telephone Number

Cell T elephone Number

Name

Home Address

City, State

Home T el ephone Number

Work Telephone Number

Cell T elephone Number

3. With this docum ent , I intend to create a durable power of attorney for health

care, which shall take ef fect upon and only during any p eriod in which, in t he opinion of

my attending phys ician, I am unable t o m ak e or c om municat e a choice regarding a

particular health-care decision. My agent shall m ake health-care dec isions as I direct

below or as I make known t o 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 m y agent beli eves to be in my best interest.

4. With this docum ent , I authorize any person, organizat ion, or entit y

involved wit h m y health care to disclose and release to my agent any and all of my

individually ident if iable health infor mation and medical recor ds in acc or danc e with

HIPAA.

5. SPECIAL PROVISIONS AND L IMITATIONS. I do NOT want t he following

treatments:

______________________________________________________________________

6. To the extent that I am permitted by law to do so, I herewith nom inate my

agent to serv e as the curator of my person, and/or in any s im ilar representative

capacity. I f I am not perm it ted by law to make a nomination, t hen I request in the

strongest possible t erm s that any court consider this nom inat ion.

7. No person who relies in good f ait h upon r epresentations by m y agent or

alternate agent shall be liable to me, m y estate, m y heirs or as signs for recognizi ng the

agent’s authorit y.

8. The powers delegated under this power of attorney are separabl e, s o t hat the

invalidity of one or more powers shall not affect any others.

BY MY SIG NAT URE I INDICATE THAT I UNDERSTAND THE PUR POSE AND

EFFECT O F THIS DOCUMENT.

I sign my name to t his form on

(Date)

at:

(City, State)

_______________________________________

(Signature)

WITNESSES

The person who signed or acknowledged t his document is per sonally known to

me and I believe him/her to be of sound mind.

First Witnes s:

Signature: _________________________________________________

Home Address:

Print Name: Date: ______________

Second Witness :

Signature: _________________________________________________

Home Address:

Print Name: Date: ______________

NOTARIZATION

STATE O F

PARISH OF

I, a Notary Public in and f or the State and

Parish aforesaid, do her eby certify that who per sonally came and

appeared bef or e me as the Principal, and executed the foregoing Durable Power of

Attorney for Health-Care in said State and Par ish, and ac knowledged said Durable

Power of Attor ney f or Health-Care as the Principa l’s voluntary act .

Witness my signatur e t his ______ day of _________________ ___, 20___.

______________________________

NOTARY PUBL IC