Louisiana Medical Power Of Attorney

Information you will need

• Principal Name
• Agent Name
• Agent Home Area Code
• Agent Home Phone Number
• Agent Work Area Code
• Agent Work Phone Number
• Agent Address
• Agent City, State, ZIP Code
• Agent Cell Area Code
• Agent Cell Phone Number
• Grant, Refuse, and Withdraw Health Care
• Medical Facilities
• Contracts for Services and Facilities
• Surgery, Medical Expenses, Prescriptions
• Prevent or Limit Communication
• Restricted Individuals
• Exempt Individuals
• Successor Agent Name
• Successor Agent Home Area Code
• Successor Agent Home Phone Number
• Successor Agent Work Area Code
• Successor Agent Work Phone Number
• Successor Agent Address
• Successor Agent City, State, ZIP Code

…and 24 more fields in the PDF.

Completed by the agent and the principal and the provider.

The form includes 4 signature lines, a notary acknowledgment, a witness section.