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 making 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 decisions made by any member of my
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 agent:
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 ______________________________,
Signature of Principal: ________________________________________________
Social Security Number: ___________ - ________ - __________.
State of Montana
County of ___________________________
Subscribed, sworn to and acknowledged before me this ___________________
of _______________________, 20____.
Notary Public for the State of Montana
Residing at ______________________________
My commission expires:____________________
This Legal guide was complied by the DPHHS Aging Services Division Legal
Services Developer. This publication is not intended to be a substitute
for legal advice. Rather, it is designed to help families become better
acquainted with some of the devices used in long term planning and to
create an awareness of the need for such planning. Future changes in
laws cannot be predicted and statements in this narrative are based
solely on those laws in force on the date of publication.
We recommend that you seek legal advice for all your planning needs.