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Durable Power Of Attorney For Medical Consent - Montana
| Durable Power Of Attorney For Medical Consent Form. This is a Montana form and can be used in Power Of Attorney Statewide . |
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DURABLE POWER OF ATTORNEY FOR MEDICAL CONSENT KNOW ALL MEN BY THESE PRESENTS: That the undersigned: NAME: _____________________________________________________________ ADDRESS: __________________________________________________________ has made, constituted and appointed, and by this document does make, constitute and appoint: NAME: _____________________________________________________________ ADDRESS: __________________________________________________________ my true and lawful attorney for me and in my name, place and stead, to do and perform all things necessary to make binding decisions concerning my medical treatment and make health care decisions for me. For the purposes of this document, Health Care Decisions means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individuals physical or mental condition. I do grant and give unto said attorney full authority to do and perform all and every act or thing which may be requisite or necessary to be done, as fully, and to all intents and purpose, as I might or could do if personally present, with full powers of substitution and revocation, hereby ratifying with full powers of substitution and revocation, all that said attorney shall lawfully do or cause to be done by virtue of this instrument. My above said attorney is granted full authority to inspect and disclose any information pertaining to my mental and physical condition, and is authorized to sign releases, waivers, or documents, including any refusal or treatment", and/or "release from liability", which may be required by a hospital or physician. THIS POWER OF ATTORNEY SHALL BECOME EFFECTIVE AS OF THE DATE I SIGN THIS DOCUMENT AND SHALL NOT BE AFFECTED BY SUBSEOUENT DISABILITY OR INCAPACITY OF THE PRINCIPAL OR LAPSE OF TIME. The laws of the State of Montana and, in particular, Chapter 72-5-501 et. seq. Montana Code Annotated, and any successor sections thereto, shall govern this power of attorney in all respects. DATED this_____________ day of, _____________, 20__. Name____________________ <<<<<<<<<********>>>>>>>>>>>>> 2STATE OF MONTANA ) : ss. County of _______________ ) On this day ________ of, __________, 20___, before me, a Notary Public for the State of Montana, personally appeared ________ known to me to be the person whose name is subscribed to the within instrument and acknowledged to me that she/he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and seal the day and year in this certificate first above written. ______________________________________ Notary Public for the State of Montana Residing at __________________________ My Commission expires ________________
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