Louisiana Medical Power of Attorney Form

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The Louisiana Medical Power of Attorney is an anticipatory legal instrument carried out to choose a healthcare agent in advance. So if someone is ever faced with negative health consequences that cause mental incapacitation, their agent will be able to make decisions on their behalf during this time. To solidify the principal-agent relationship, the executor must transcribe the following details to the form; the agent’s information (name, address, phone numbers), types of medical decisions authorized, and any limitations or provisions surrounding the authority granted (if applicable). This document comes equipped with an acknowledgment section for two (2) witnesses (required) and another for a notary public (optional).

Other Versions (4)

Franciscan Missionaries of Our Lady Health System Version

Download: Adobe PDF

 

 

 


LSU Health Version

Download: Adobe PDF

 

 

 


Ochsner Health System Version

Download: Adobe PDF

 

 

 


Spanish/Español Version

Download: Adobe PDF

 

 

 

Additional Resources

Related Forms (6)

Advance Directive (Medical POA & Living Will)

Download: Adobe PDF

 

 

 


Advance Directive for Mental Health Treatment

Download: Adobe PDF
Laws: RS 28:221 et sec.

 

 


Advance Directive Wallet Cards

Download: Adobe PDF

 

 

 


Durable (Financial) Power of Attorney

Download: Adobe PDF, MS Word (.docx)

 

 

 


HIPAA Authorization Form (specific to Blue Cross, Blue Shield, & HMO)

Download: Adobe PDF

 

 

 


Physician Orders for Scope of Treatment (LaPOST) Form

Download: Adobe PDF
Spanish Version: Adobe PDF
Laws: RS 40:1155.1 et seq.