Louisiana Medical Power of Attorney Form

The Louisiana medical power of attorney form is a legal document that will permit the Principal to assign an Agent to attend to their medical decisions in the event of incapacitation or disability. The Agent will only allow the Agent to make medical decision and will not grant permission to make decisions with regard to the Principal’s financials or real property. The Principal may select the powers that they choose to grant to the Agent.

This document must be witnessed by a Notary Public. This document may also be revoked at the discretion of the Principal. The Principal must simply place the notice in writing in attention to the Agent, making the date of revocation available on the date of their choosing.

How to Write

Step 1 – The Parties – Enter the following:

  • The Principal’s name (printed)
  • AND
  • The Agent’s name (printed)
  • Enter the Agent’s name in the “name” field
  • Home Address
  • City, State
  • Home Telephone Number
  • Work Telephone Number
  • Cell Number

Step 2 – Principal’s Selection of Powers Granted to the Agent – The Principal must read the statements (A through E) and check the box(es) that would apply. The Principal may select one or all of the options:

Step 3 – Successor Agent(s) – In the event that the initially selected Agents becomes unable to serve the Principal, listing successor agents that the Principal trusts to attend to their health care decisions if needed:

  • Enter the Names of the Successor Agents into their respective fields
  • Home Addresses
  • City, State
  • Home Telephone Number
  • Work Telephone Number
  • Cell Number

Step 4 – Special Provisions and Limitations –

  • The Principal may enter treatments they do NOT want by placing the information into the line provided

Step 5 – Signatures – Must be submitted before a notary:

  • Enter the Principal’s Signature
  • Enter the signature of the first witness
  • Provide the complete home address
  • Printed Name
  • Enter the date of the signature in mm/dd/yyyy format
  • AND
  • Enter the signature second withess
  • Provide their complete home address
  • Printed Name

Step 6 – Notary –

As the document has been witnessed by a state licensed Notary Public, the notary will enter their required information and shall apply the official seal (if any) in acknowledgement.