Montana Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with the laws of the State of Montana. It allows you to designate an individual to make healthcare decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Date of Birth: ________________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Phone Number: ______________________
Durability of the Power of Attorney:
This Medical Power of Attorney shall remain in effect even if I become incapacitated.
Limitations on Agent’s Authority:
The agent shall have the authority to make decisions regarding my medical treatment, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
Signature:
I, ______________________________ (Principal), hereby designate the above-named individual as my agent to make healthcare decisions on my behalf.
Principal’s Signature: ______________________________
Date: ______________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness 1 Name: ______________________________
- Witness 1 Signature: ___________________________
- Witness 2 Name: ______________________________
- Witness 2 Signature: ___________________________
Notarization:
State of Montana, County of ______________
Subscribed and sworn before me on this ____ day of ____________, 20__.
Notary Public Signature: ___________________________
My Commission Expires: ___________________________