Structure
In Louisiana, the Medical Power of Attorney form serves as a crucial legal document that empowers individuals to designate a trusted person to make healthcare decisions on their behalf in the event they become incapacitated. This form is not just a simple assignment of authority; it encompasses a variety of important aspects that ensure a person's medical preferences are honored when they cannot communicate them. The appointed individual, often referred to as an agent or proxy, can make decisions regarding medical treatments, surgical procedures, and end-of-life care, reflecting the wishes of the individual who created the document. Furthermore, the form includes provisions for discussing medical information with healthcare providers, ensuring that the agent has the necessary access to make informed choices. It is vital for individuals to consider their values and preferences when completing this form, as it can significantly impact their medical care and quality of life during critical moments. Additionally, understanding the legal requirements and implications of the Medical Power of Attorney in Louisiana can help ensure that the document is valid and enforceable, providing peace of mind for both the individual and their loved ones.
Sample - Louisiana Medical Power of Attorney Form
This Louisiana Medical Power of Attorney is a legal document that allows an individual (hereafter referred to as the "Principal") to designate another person (referred to as the "Agent") to make health care decisions on their behalf should they become unable to do so. This document is created in accordance with the Louisiana Revised Statutes §40:1151-1169, also known as the Louisiana Health Care Consent Act.
Principal Information:
- Full Name: ___________________________________________________
- Address: ______________________________________________________
- City: ___________________________ State: LA Zip Code: ___________
- Date of Birth: ___________________ Phone Number: ________________
Agent Information:
- Full Name: ___________________________________________________
- Address: ______________________________________________________
- City: ___________________________ State: LA Zip Code: ___________
- Date of Birth: ___________________ Phone Number: ________________
Alternate Agent Information (optional):
- Full Name: ___________________________________________________
- Address: ______________________________________________________
- City: ___________________________ State: LA Zip Code: ___________
- Date of Birth: ___________________ Phone Number: ________________
By this document, I grant my Agent the power to make any and all health care decisions for me, consistent with the wishes I have expressed herein, or otherwise known to my Agent. In the absence of such knowledge, my Agent is authorized to make health care decisions for me that my Agent believes to be in my best interest. This power includes, but is not limited to, the power to:
- Consent, refuse, or withdraw consent to any type of health care, including medical and surgical treatments.
- Admit or discharge me from any hospital, hospice, or other health care facility.
- Have access to my medical records and information to the extent permitted by law, and communicate with my health care providers.
- Make decisions regarding my body's anatomical gifts, burial or disposition upon my death.
This document does not authorize my Agent to make decisions about my property and finances. It strictly pertains to health care decisions.
Signature and Acknowledgment:
Principal's Signature: __________________________________ Date: ____________
Principal's Printed Name: _____________________________________________
Agent's Signature: __________________________________ Date: _____________
Agent's Printed Name: ________________________________________________
(Optional) Alternate Agent's Signature: __________________________ Date: _____________
(Optional) Alternate Agent's Printed Name: _________________________________________
This document was signed in the presence of two witnesses, who acknowledge that the Principal appears to be of sound mind and not under duress, fraud, or undue influence.
Witness 1 Signature: __________________________________ Date: ____________
Witness 1 Printed Name: _______________________________________________
Witness 2 Signature: __________________________________ Date: ____________
Witness 2 Printed Name: _______________________________________________
State of Louisiana
Parish of _______________________________
This Medical Power of Attorney shall remain effective indefinitely unless I revoke it in writing or upon my death, subject to applicable Louisiana laws.
Document Details
| Fact Name | Description |
|---|---|
| Definition | A Louisiana Medical Power of Attorney allows an individual to designate someone else to make healthcare decisions on their behalf if they become incapacitated. |
| Governing Law | This form is governed by Louisiana Revised Statutes, specifically RS 40:1151.2, which outlines the legal framework for advance health care directives. |
| Requirements | The form must be signed by the principal and two witnesses or a notary public to be legally valid. |
| Revocation | A principal can revoke the Medical Power of Attorney at any time, as long as they are mentally competent, by providing written notice to the designated agent. |
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