Louisiana Durable Medical Power of Attorney Form

The Louisiana Power Of Attorney For Health Care Decisions form legally permits an appointed person, the `Agent, to make decisions regarding the medical treatment of a patient and on their behalf if they become incoherent and unable to communicate because of illness, for example being in a coma. The document is in accordance with RS 28:224RS 40:1151.4, and it requires signatures from two witnesses or oral confirmation in the presence of two witnesses.

How to Write

Louisiana Health Care Power Of Attorney

1) The principal must appoint an agent.

  • Name of principal.
  • Name of agent.
  • Address of agent.
  • Home/Work and Cell telephone numbers.


Decisions Regarding Health Care Provision

The principal must decide the type of health care they will require by checking the relevant box.

  • A) Check box to grant agent authority to refuse or withdraw treatment.
  • B) Check box to allow the agent`s involvement with health care professionals.
  • C) Check box to agent to admit or discharge the principal to or from a health care facility.
  • D) Check box to allow the agent to agree to treatments and procedures.
  • E) Check box to allow the agent ot make decisions regarding surgery, expenses and prescriptions.


Alternative Agents

2) The principal must appoint alternative agents.

  • Agent`s names.
  • Agent`s addresses.
  • Home/Work and Cell telephone numbers.


Special Provisions And Limitations

5) The principal must enter the details of any specific treatments they DO NOT wish to receive.



The personal details of the persons involved with this document must be entered.

  • Date.
  • City & State.
  • Signature of principal.
  • Witnesses signatures.
  • Witnesses names.
  • Witnesses addresses.
  • Date.
  • Notary`s name.
  • Principal`s name.
  • Date.
  • Notary`s signature.