Healthcare Power Of Attorney printable pdf download

Healthcare Power Of Attorney

STATE OF LOUISIANA

PARISH OF ___________________

HEALTHCARE POWER OF ATTORNEY

BEFORE ME, the undersigned Notary Public and witnesses personally came and appeared:

___________________________, SSN: XXX-XX-_____, (Principal)

And __________________ and __________________ (each individually “AGENT”, who may

act without notice or consent of any other AGENT.)

ARTICLE 1

HEALTH CARE

I give my Agent all powers regarding the following health care matters that I could exercise on

my own behalf, if capable of doing so. My Agent may:

1.1

Medical Records. Have access any medical information in any form regarding

my physical or mental condition, and to execute such consents as may be necessary to

obtain it; consent to the disclosure of my medical information to others.

1.2

Professionals. Retain, compensate and discharge any health care professionals

my Agent deems necessary to examine, evaluate or treat me, whether for emergency,

elective, recuperative, convalescent or other care.

1.3

Institutionalization. Admit me to any health care facility recommended by a

qualified health care professional, whether for physical or mental care or treatment, and

remove me from such institution at any time, even if contrary to medical advice.

1.4

Treatment. Consent on my behalf to tests, treatment, medication, surgery, organ

transplant or other procedures, and to revoke that consent, even if contrary to medical

advice.

1.5

Chemical Dependency. Consent on my behalf to a course of treatment for

chemical dependency, whether suspected or diagnosed, or to revoke such consent.

1.6

Pain Relief. Consent on my behalf to pain relief procedures, even if they are

unconventional or experimental, and even if their use may rick addiction, injury or

foreshortening my life.

1.7

Releases. Release from liability any health care professional or institution that

acts on my behalf in reliance on my Agent.

Law Offices of Regina Scotto Wedig, LLC

Healthcare POA

Healthcare Power Of Attorney