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 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: ____________________________________________State of MontanaCounty of __________________________________Subscribed, sworn to and acknowledged before me this __________dayof _______________________, ___________._______________________________________ (Signature of Notarial Officer)(NOTARIAL SEAL) Printed Name: ___________________________Notary Public for the State of MontanaResiding at: _____________________________ My Commission Expires: __________________