Fillable Printable Medical Power of Attorney Form - Montana

Medical Power of Attorney Form - Montana

DURABLE POWER OF ATTORNEY

FOR HEALTH CARE AND MEDICAL TREATMENT

I, ______________________, of the City of __________________________, State of

Montana do hereby make, constitute, nominate and appoint _________________presently

residing in ______________________, County, State of Montana, as my true and lawful

attorney-in-fact to act for me, and in my place and stead for the purpose of making any and all

decisions regarding my health and, medical care and treatment at any time that I may be, by

reason of physical, mental disability, incompetency or incapacity, incapable of make decisions

on my behalf.

1. I grant said attorney-in-fact complete and full authority to do and perform all

and every act and thing whatsoever requisite, proper and necessary to be done in

the exercise of the rights herein granted, as fully for all intents and purposes as I

might or could do if personally present and able with full power of substitution or

revocation, hereby ratifying and confirming all that said attorney-in-fact shall

lawfully do or cause to be done by virtue of this power of attorney and the rights

and powers granted herein.

2. If, at any time, I am unable to make or communicate decisions concerning my

medical care and treatment, by virtue of physical, mental or emotional disability,

incompetency, incapacity, illness or otherwise, my said attorney-in-fact shall have

the authority to make all health care decisions and all medical care and treatment

decisions for me and on my behalf, including consenting or refusing to consent to

any care, treatment, service or procedure to maintain, diagnose or treat my mental

or physical condition.

3. In the absence of my ability to give directions regarding my health care, it is

my intention that my said attorney-in-fact shall exercise this specific grant of

authority and that such exercise shall be honored by my family, physicians,

nurses, and any other health care provider(s) or facility in which or by which I

may be treated, as a final expression of my legal rights.

4. This power of attorney is durable and will continue to be effective if I become

disabled, incapacitated, or incompetent.

5. This durable power of attorney is effective in any state that I may seek or

receive medical-treatment and health care.

6. I specifically direct all health care providers, including physicians, nurses,

therapists and medical and hospital staff to follow the directions of my attorney-

in-fact and such decisions are superior to and shall take precedence over any

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__________________________________________________________________

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decisions made by any member of my family.

7. The rights, powers, and authority of said attorney-in-fact herein granted shall

commence and be in full force and effect immediately.

8. If any agent named by me dies, becomes incompetent, resigns or refuses to

accept the office of agent, I name the following persons (each to act alone and

successively, in the order named) as successor(s) to the agen t:

A.____________________________________________

B.____________________________________________

9. Special instructions: On the following lines I give special instructions limiting

or extending the powers granted to my agent.

10. 1 hereby designate _________________ to determine whether I am unable to

make or communicate decisions concerning my medical care and treatment by

virtue of my physical, mental, or emotional disability, incompetency, incapacity,

illness or otherwise. This determination will be provided in writing and attached

to this Durable Power of Attorney For Health Care and Medical Treatment.

Dated this __________ day of _______________, 20____.

(Signature)

STATE OF MONTANA )

: ss

COUNTY OF ___________ )

Subscribed, sworn to and acknowledged before me this __________day of

_______________________, 20_____.

(Notarial Seal)

(

gnature o

Notary

)

(

nte

Name

)

NOTARY PUBLIC FOR THE STATE OF MONTANA

Residing at:

My Commission Expires:

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