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Louisiana Health Care Power of Attorney Form

Expressly appoints a health care agent if the principal becomes unable to make health care decisions, subject to the initialed powers and written limits.

Jurisdiction
Louisiana
Purpose
Medical & health care
Source / form version
Undated three-page legal-aid template.
Resource format
PDF
Signing
The template includes the principal’s signature and two witness declarations. Its separate notarization block is explicitly labeled optional.
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Sources checked: 2026-11-13. General information, not individual legal advice.

Select powers one option at a time

The Louisiana legal-aid template provides paired choices to grant or withhold particular powers. These include treatment consent, admission or discharge, health-related contracts, and specified visitation decisions. Initial one choice for each option. Civil Code article 2997 requires express health care authority, which is why a vague financial appointment should not substitute for this document.

Sources: [1] [3] [4]

Add backups and usable treatment instructions

You can name two backup agents in the order they should serve. The second page provides separate spaces for treatments wanted, treatments refused, and other limits. Discuss the instructions with your agent and care team so that medical terms and your intended limits are understood. The document also contains a release of health information to the agent.

Sources: [1] [3] [4]

Complete the publisher’s execution blocks

The final page has the principal’s signature and two witness declarations concerning identity and sound mind. A further notarial acknowledgment is marked optional. Follow those blocks rather than importing another state’s health care signing checklist. Give the complete signed document to the primary agent, backups, and treating providers, and replace old copies when making changes.

Sources: [1] [3] [4]

Common questions

Does the agent begin making decisions immediately?

This template describes an agent acting if you become unable to make your own health care decisions. Read the grant and any special instructions before signing.

Sources: [1] [3] [4]

Can I restrict visits or particular treatments?

The template expressly asks about visitation authority and provides treatment-limit spaces. These choices can have significant consequences, so specify your wishes rather than relying on an assumed default.

Sources: [1] [3] [4]

Related forms and guides

Sources and verification

  1. Louisiana Civil Legal Navigator / Lagniappe Law Lab: source and instructions (opens in a new tab)
  2. Direct PDF (opens in a new tab)
  3. Civil Code article 2997 — express health care and visitation authority (opens in a new tab)
  4. Civil Code article 2993 — form (opens in a new tab)

Primary publisher file and instructions checked on 2026-11-12. External link only; no independent attorney review or suitability determination is claimed.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.