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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
. DESIGNATION OF HEALTH CARE AGENT. I, , of , , appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
NOTICE: Generally you should not appoint any of the following persons as your Agent:
(1) your treating physician or health care provider;
(2) an employee of your physician or health care provider unless the person is your relative;
(3) your residential care provider; or
(4) an employee of your residential care provider unless the person is your relative.
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so.
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. GENERAL PROVISIONS.
1. HOLD HARMLESS. I agree that any third party who receives a copy of this document may act under it. Revocation of the Power of Attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this Power of Attorney.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST DATE AND SIGN THIS DOCUMENT)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of ____________________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| Parish |
has been personally known to me and I believe him or her to be of sound mind. I am not related to by blood or marriage and would not be entitled to any portion of 's estate.
| Witness Signature: | ________________________________________ |
| Witness Signature: | ________________________________________ |
State of Louisiana
Parish of _________________________
Be it known on this _____ day of the month of ____________________, _____, before me, the undersigned authority, personally came and appeared , to me personally known and known by me to be the person whose genuine signature is affixed to the foregoing document, who signed said document before me and who acknowledged, in my presence, that he/she signed the above and foregoing document as his/her own free act and deed and for the uses and purposes therein set forth and apparent.
In witness whereof, the said appearer has signed these presents and I have hereunto affixed my hand and seal on the day and date first above written.
________________________________________
(Signature of Officer)
(Seal)
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It's very easy to grant or receive the support you need with a free Louisiana Medical Power of Attorney template from Rocket Lawyer:
This solution is, in most cases, much less expensive than meeting and hiring your average provider. If necessary, you may fill out this Medical PoA on behalf of an elderly parent, a spouse, or another family member, and then help them sign when ready. Please remember that for a PoA form to be considered valid, the principal must be mentally competent at the time of signing. In the event that the principal is already unable to make their own decisions, a court-appointed conservatorship may be required. When managing such a situation, it's a good idea to connect with an attorney .
Anyone who is over 18 years old should have a Medical Power of Attorney. While it is tough to acknowledge, there could come a time when you aren't able to make important decisions on your own. Common circumstances where power of attorney might be helpful include:
Regardless of whether this Louisiana Medical Power of Attorney is being produced in response to an urgent issue or as part of a forward-looking plan, witnesses and notarization are highly encouraged as a best practice for protecting your agent if their power and authority are disputed by a third party.
At times, in researching the subjects of elder care and estate planning, you or a loved one may see the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together or interchangeably. In reality, they are the same. That being said, you should keep in mind that it's entirely possible to give agency over affairs that aren't health-related. In that case, "proxy" is not usually used.
Louisiana Medical PoA forms are typically easy to make, but you or your agent(s) could need legal advice. Getting a second pair of eyes on your document could take longer than you would expect if you attempt to do it by yourself. An alternate approach would be to request help from attorney services at Rocket Lawyer. Rocket Lawyer members can request a document review from an Rocket Lawyer network attorney with relevant experience or ask additional legal questions. As always, you can Live Confidently® knowing that Rocket Lawyer is by your side.
The fees associated with hiring an attorney to create a Medical Power of Attorney might total between $200 and $500, depending on your location. Unlike many other sites that you may stumble upon, Rocket Lawyer offers much more than a Power of Attorney template. If you ever need support from a lawyer, your Rocket Lawyer membership offers up to a 40% discount when you hire an attorney.
When you've created your Healthcare PoA document on Rocket Lawyer, you'll be able to open it on any device, anytime. As a Rocket Lawyer member, you may edit it, print it, and/or sign it. Attached alongside each Power of Attorney form, there's a checklist of recommended steps you can take to finalize the document. You should make sure to send a final copy of your signed document to your agent(s) and care providers.
The rules and restrictions will be different by state; however, in Louisiana, your document must be signed by two witnesses. Finally, as a basic rule, your witness(es) will need to be 18 years old or older, and none of them should simultaneously be designated as your Power of Attorney agent.
See Louisiana Medical/Healthcare Power of Attorney law: CC 2997
