Fill and Sign the Montana Durable Power of Attorney for Health Care and Medical Treatment Form

13 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. 14 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 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 agent: 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 __________________________, ___________. Signature of Principal: ____________________________________________ 15 Social Security Number: ___________ - ________ - __________. State of Montana County of ___________________________________ Subscribed, sworn to and acknowledged before me this __________day of _______________________, ___________. (Notarial Seal) ___________________________________ Notary Public For the State of Montana Residing at ________________________ My commission expires: _____________