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:
A.
Name
Home Address
Ci
ty, State
Home T el ephone Number
Work Telephone Number
Cell T elephone Number
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