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Louisiana I believe him or her to be of sound mind. Witness ______________________________________________________ Witness ______________________________________________________ tally competent to make this declaration. Signed ___________________________________________ City, Parish and State of Residence ____________________ The declarant has been personally known to me and lling to act on my behalf, my declaration will nevertheless be given effect should the above-discussed circumstance arise. I understand the full import of this declaration and I am emotionally and menagent and alternate agent named above, and I trust his/her judgment on my behalf. I understand that if I have not filled in any name in this clause or if the agent I have chosen is unavailable or unwiilling or unavailable to act, by my successor attorney-in-fact, unless the attending physician determines that I have decisional capacity. I have discussed my desires concerning terminal care with my and is not affected by physical disability or mental incompetence. The determination of whether I can make my own medical decisions is to be made by my attorney-in-fact, or if he or she is unable, unwey-in-fact) _____________________________________________ (telephone number of successor attorney-in-fact) This power of attorney becomes effective when I can no longer make my own medical decisions, ney-in-fact, I hereby appoint: _______________________________________________________ (name of successor attorney-in-fact) _______________________________________________ (address of successor attornersible condition and (2) comatose, incompetent or otherwise mentally or physically incapable of communication. In the event the person I appoint is unable, unwilling or unavailable to act as my attor all medical treatment decisions for me, including decisions to withhold or withdraw any form of life-sustaining procedure on my behalf should I be (1) diagnosed as suffering from a terminal and irrev______________________________________________ (address of attorney-infact) ______________________________________________________ (telephone number of attorney-in-fact) as my attorney-in-fact to make_____________________________________________________, being of sound mind, willfully and voluntarily appoint: ___________________________________________________ (name of attorney-in-fact) __________forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Power of Attorney for Health Care Declaration made this _______________ day of __________ (month, year). I, _____y whenever a document is negotiated with another party. Any -3- possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these ithout consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorneare not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used ws are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms received in his office. Until the notation has been indicated on the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These formf state's office may be revoked by the filing of a written notice of revocation in that office. The secretary of state shall indicate on the declaration the date and time the notice of revocation was hysician. (c) The attending physician shall record in the patient's medical records the time and date when notification of the revocation was received. B. A declaration registered with the secretary ononverbal expression by the declarant of the intent to revoke the declaration. (b) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending p and dated by the declarant. (b) The attending physician shall record in the patient's medical record the time and date when notification of the written revocation was received. (3) (a) By an oral or therwise destroyed by the declarant or by some person in the presence of and at the direction of the declarant. (2) (a) By a written revocation of the declarant expressing the intent to revoke, signedon may be revoked at any time by the declarant without regard to his or her mental state or competency by any of the following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or ornishing of information concerning the existence of a declaration, the disclosure of its contents, or the providing of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaratiwenty dollars for registering a declaration and issuing a do-not-resuscitate identification brace` and a fee of five dollars for filing a -2- notice of revocation. No charge shall be made for the fum the existence of such declaration or obtain a copy thereof prior to the withholding or withdrawal of medical treatment or life-sustaining procedures. (3) The secretary of state may charge a fee of tf the declaration or a facsimile thereof transmitted from the office of the secretary of state shall be deemed authentic. However, nothing herein requires a physician or health care facility to confirr in writing, request the secretary of state to confirm immediately the existence of a declaration and to disclose the contents thereof for any patient believed to be a resident of Louisiana. A copy oy. The do-not-resuscitate identification bracelet must include the patient's name, date of birth, and the phrase "DO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally othe original, multiple original, or a certified copy of the declaration. (b) The secretary of state shall issue a do-not-resuscitate identification bracelet to qualified patients listed in the registrss it clearly provides to the contrary. D. (1) (a) The secretary of state shall establish a declaration registry in which a person, or his attorney, if authorized by the person to do so, may register declarant is in a continual profound comatose state shall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unleend the directions in t` declaration are severable. (3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustaining procedures in the event that the ld any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can ` given effect without the invalid direction, and to this should he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications (see form enclosed below): (2) Shouneed not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant ian shall promptly make a recitation of the reasons the declarant could not make a written declaration and make the recitation a part of the patient's medical records. C. (1) The declaration may, but copy of the declaration, if written, or a notation of the existence of a registered declaration, a part of the declarant's medical record. -1- (4) If the declaration is oral or nonverbal, the physicaration. (3) Any attending physician who is so notified, or who determines directly or is advised by the health care facility that a declaration is registered shall promptly make the declaration or a may notify the physician of the existence of the declaration. In addition, the attending physician or health care facility may directly contact the registry to determine the existence of any such declify his attending physician that a declaration has been made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person f two witnesses by any nonwritten means of communication at any time subsequent to the diagnosis of a terminal and irreversible condition. B. (1) It shall be the responsibility of the declarant to not and irreversible condition. (2) A written declaration shall be signed by the declarant in the presence of two witnesses. (3) An oral or nonverbal declaration may be made by an adult in the presence oion bracelets A. (1) Any adult person may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a terminalisiana Statutes relating to the Louisiana Power of Attorney for Health Care Form. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identificatttorney for Health Care Form. This Louisiana Power of Attorney for Health Care is based on Title 40 Section 1299.58.3 et. Seq. of the Louisiana Statutes. The following are useful excerpts from the LouInformation and Instructions Louisiana Power of Attorney for Health Care This package contains (1) Information and Instruction for Louisiana Power of Attorney for Health Care; (2) Louisiana Power of A Louisiana