Montana Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Montana Uniform Health Care Decisions Act (Mont. Code Ann. §§ 50-9-101 through 50-9-111). It allows you, the Principal, to designate another person, referred to as the Agent, to make health care decisions on your behalf if you are incapable of making or communicating decisions yourself.
Principal Information
Name: ___________________________________
Address: __________________________________
City, State, Zip: ___________________________
Phone Number: _____________________________
Date of Birth: _____________________________
Agent Information
Name: ___________________________________
Address: __________________________________
City, State, Zip: ___________________________
Phone Number: _____________________________
Alternate Phone Number: ____________________
Alternate Agent Information (Optional)
If the primary Agent is not available, the following individual will serve as the alternate Agent:
Name: ___________________________________
Address: __________________________________
City, State, Zip: ___________________________
Phone Number: _____________________________
Alternate Phone Number: ____________________
Authority of Agent
This document grants the Agent the following powers, subject to any limitations specified:
- Decision-making authority regarding medical treatment if the Principal is unable to make or communicate decisions.
- The power to consult with healthcare providers and review medical records.
- The authority to make decisions about the hiring and firing of medical personnel, hospitalization, and treatment options.
- The power to make decisions regarding life-sustaining treatment.
Specific Limitations
If there are any specific limitations on the Agent's authority, describe them here:
____________________________________________________________
____________________________________________________________
Effective Date and Duration
This Medical Power of Attorney becomes effective upon the incapacity of the Principal and remains in effect until the Principal's death, unless revoked earlier by the Principal in writing.
Signatures
This document must be signed by the Principal, the Agent, and an alternate Agent (if applicable) in the presence of two witnesses, who also must sign the document.
Principal's Signature: ______________________________ Date: ________________
Agent's Signature: ______________________________ Date: ________________
Alternate Agent's Signature (if applicable): ______________________________ Date: ________________
Witness 1 Signature: ______________________________ Date: ________________
Witness 2 Signature: ______________________________ Date: ________________
Witness Affirmation
By our signatures below, we affirm that the Principal appears to be of sound mind and under no duress, fraud, or undue influence at the time of signing this Medical Power of Attorney.
Additional Acknowledgments
This document does not authorize the Agent to make financial decisions on behalf of the Principal.