Montana Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Montana Uniform Health Care Decisions Act (Montana Code Annotated §50-9-101 et seq.). It grants authority to a designated person, herein referred to as the "Agent", to make health care decisions on behalf of the undersigned Principal, when the Principal is unable to make or communicate health care decisions.
Principal Information
Full Name: ___________________________________________________________
Date of Birth: _________________________________________________________
Address: ______________________________________________________________
City, State, Zip: _______________________________________________________
Telephone Number: ______________________________________________________
Agent Information
Full Name: ___________________________________________________________
Relationship to Principal: ______________________________________________
Address: ______________________________________________________________
City, State, Zip: _______________________________________________________
Alternate Telephone Number: _____________________________________________
Primary Telephone Number: ______________________________________________
Alternate Agent Information
If the initial Agent is unable, unwilling, or unavailable to serve, an alternate Agent may act in their place. The following information pertains to the designated alternate Agent.
Full Name: ___________________________________________________________
Relationship to Principal: ______________________________________________
Address: ______________________________________________________________
City, State, Zip: _______________________________________________________
Primary Telephone Number: ______________________________________________
Alternate Telephone Number: _____________________________________________
Authority of Agent
The Agent is authorized to make all health care decisions for the Principal when the Principal is determined to be unable to make health care decisions for themselves. These decisions include, but are not limited to:
- Consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- The decision to make anatomical gifts, authorize autopsies, and direct disposition of the body.
Special Instructions
In the space below, the Principal may specify limitations on the Agent’s authority, indicate desires regarding artificial life support, and articulate any other wishes concerning health care decisions.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signatures
This document must be signed by the Principal in the presence of two witnesses or a notary public. Witnesses to this document must not be related to the Principal by blood or marriage, must not be entitled to any portion of the estate of the Principal under any will or by operation of law, and must not be directly financially responsible for the Principal’s medical care.
Principal’s Signature: ___________________________________________________
Date: __________________________________________________________________
Agent’s Signature: ______________________________________________________
Date: __________________________________________________________________
Alternate Agent’s Signature: ____________________________________________
Date: __________________________________________________________________
Witness 1 Signature: ____________________________________________________
Print Name: ____________________________________________________________
Date: __________________________________________________________________
Witness 2 Signature: ____________________________________________________
Print Name: ____________________________________________________________
Date: __________________________________________________________________
or
Notary Public Signature: _________________________________________________
Commission Expires: ____________________________________________________