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Montana _____ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ __________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _________________________________________________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ The declarant voluntarily signed this document in my presence. ______ (Declarant's Signature) Name: ____________________________________________________________________ Address: __________________________________________________________________ _____________________s not necessary to my comfort or to alleviate pain. Signed this _____________ day of ____________, ______________ (month, year) ______________________________________________________________________garding my medical treatment, I direct my attending physician, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw treatment that only prolongs the process of dying and ithat, without the administration of lifesustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions real. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION If I should have an incurable or irreversible condition tion. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professionme to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situaed as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from tinstructions of a designee under 50-9-103(1) or comply with the transfer requirements of 50-9-203. [_] These forms are provided "as is" and no implied or express warranties have been made or are providWill Information & Instructions ­ Page 3 (2) When the declaration becomes operative, the attending physician and other health care providers shall act in accordance with its provisions and with the iician; and (b) the declarant is determined by the attending physician to be in a terminal condition and no longer able to make decisions regarding administration of life-sustaining treatment. Living ovider shall make the revocation a part of the declarant's medical record. 50-9-105. When declaration operative. (1) A declaration becomes operative when: (a) it is communicated to the attending physare provider is not effective unless the attending physician is informed of it before the qualified patient is in need of life-sustaining treatment. (2) The attending physician or other health care prate the revocation to the attending physician at the earliest opportunity. A revocation communicated to a person other than the attending physician, emergency medical services personnel, or a health ch care provider by the declarant or a witness to the revocation. A health care provider or emergency medical services personnel witnessing a revocation shall act upon the revocation and shall communicarant may revoke a declaration at any time and in any manner, without regard to mental or physical condition. A revocation is effective upon its communication to the attending physician or other healt(2) A declaration directing a physician to withhold or withdraw life-sustaining treatment may, but need not, be in the following form: (see form below) 50-9-104. Revocation of declaration. (1) A decltion, and witnessed by two individuals. A physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration complies with this chapter and is valid. and 18 or more years of age to make decisions governing the withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant, or another at the declarant's direcnd and 18 or more years of age may execute at any time a declaration governing the withholding or withdrawal of life-sustaining treatment. The declarant may designate another individual of sound mind n the opinion of the attending physician, result in death within a relatively short time. 50-9-103. Declaration relating to use of life-sustaining treatment -- designee. (1) An individual of sound missession subject to the jurisdiction of the United States. (14) "Terminal condition" means an incurable or irreversible condition that, without the administration of life-sustaining treatment, will, ition is on file and that the individual is a qualified patient. (13) "State" means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular pounity emergency medical services agencies and licensed hospice and home health Living Will Information & Instructions ­ Page 2 agencies, that signifies and certifies that a valid and current declaraion. (12) "Reliable documentation" means a standardized, statewide identification card or form or a necklace or bracelet of uniform design, adopted by a written, formal understanding of the local commified patient" means a patient 18 years of age or older who has executed a declaration in accordance with this chapter and who has been determined by the attending physician to be in a terminal conditnt, governmental subdivision or agency, or any other legal or commercial entity. (10) "Physician" means an individual licensed under Title 37, chapter 3, to practice medicine in this state. (11) "Qualqualified patient under 50-9-202 by emergency medical service personnel. (9) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, governmeped, community- wide method or a standardized, statewide method developed by the department and approved by the board, of providing palliative care to and withholding life-sustaining treatment from a ining treatment" means any medical procedure or intervention that, when administered to a qualified patient, serves only to prolong the dying process. (8) "Living will protocol" means a locally develo" means a person who is licensed, certified, or otherwise authorized by the laws of this state to administer health care in the ordinary course of business or practice of a profession. (7) "Life-sustaters, law enforcement officers, first responders, emergency medical technicians, or other emergency services personnel acting within the ordinary course of their professions. (6) "Health care providerequirements of 50-9103. (4) "Department" means the department of public health and human services provided for in 2-15-2201. (5) "Emergency medical services personnel" means paid or volunteer firefighs primary responsibility for the treatment and care of the patient. (2) "Board" means the Montana state board of medical examiners. (3) "Declaration" means a document executed in accordance with the relating to Living Wills. 50-9-102. Definitions . As used in this chapter, the following definitions apply: (1) "Attending physician" means the physician selected by or assigned to the patient, who haing Will. This Montana Living Will is based on Title 50 Chapter 9 Section 101 et. Seq. of the Montana Code Annotated. For your convenience, we have included useful excerpts from the Montana Statutes r__________________ Address: ___________________________ Information and Instructions Montana Living Will This package contains (1) Information and Instruction for Montana Living Will; (2) Montana Liv____________________________________ ______________________________________ Name and address of designee(s). Name: ____________________________ Address: ___________________________ Name: _______________________________________________ (Witness Signature) (Witness Signature) Print Name: Print Name: ______________________________________ ______________________________________ Address: Address: ____________________________ City, County, and State of Residence ______________________________ The declarant voluntarily signed this document in my presence. ______________________________________ _hdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain. Signed this ______day of _______________________, 20____ Signature. _________________. If the individual I have appointed is not reasonably available or is unwilling to serve, I direct my attending physician, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or witarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pursuant to the Montana Rights of the Terminally Ill Act____________________________________________________ or, if he or she is not reasonably available or is unwilling to serve, _________________________________________ to make decisions on my behalf regsustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I appoint ers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care & Declaration If I should have an incurable and irreversible condition that, without the administration of lifego tiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimttorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is net a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an ano implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are noidual to make decisions governing the withholding or withdrawal of life-sustaining treatment may, but need not, be in the following form (see below for form): [_] These forms are provided "as is" and ll act in accordance with its provisions and with the instructions of a designee under 50-9-103(1) or comply with the transfer requirements of 50-9-203. (3) A declaration that designates another indivtion and no longer able to make decisions regarding administration of life-sustaining treatment. (2) When the declaration becomes operative, the attending physician and other health care providers shan operative. (1) A declaration becomes operative when: (a) it is communicated to the attending physician; and -2- (b) the declarant is determined by the attending physician to be in a terminal condiatient is in need of life-sustaining treatment. (2) The attending physician or other health care provider shall make the revocation a part of the declarant's medical record. 50-9-105. When declaratioto a person other than the attending physician, emergency medical services personnel, or a health care provider is not effective unless the attending physician is informed of it before the qualified pmedical services personnel witnessing a revocation shall act upon the revocation and shall communicate the revocation to the attending physician at the earliest opportunity. A revocation communicated ndition. A revocation is effective upon its communication to the attending physician or other health care provider by the declarant or a witness to the revocation. A health care provider or emergency , result in death within a relatively short time. 50-9-104. Revocation of declaration. (1) A declarant ma y revoke a declaration at any time and in any manner, without regard to mental or physical cothe United States. (14) "Terminal condition" means an incurable or irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of the attending physicianis a qualified patient. (13) "State" means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of local community emergency medical services agencies and licensed hospice and home health agencies, that signifies and certifies that a valid and current declaration is on file and that the individual nal condition. (12) "Reliable documentation" means a standardized, statewide identification card or form or a necklace or bracelet of uniform design, adopted by a written, formal understanding of the (11) "Qualified patient" means a patient 18 years of age or older who has executed a declaration in accordance with this chapter and who has been determined by the attending physician to be in a termirnment, governmental subdivision or agency, or any other legal or commercial entity. -1- (10) "Physician" means an individual licensed under Title 37, chapter 3, to practice medicine in this state. m a qualified patient under 50-9-202 by emergency medical service personnel. (9) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, goveveloped, community- wide method or a standardized, statewide method developed by the department and approved by the board, of providing palliative care to and withholding life-sustaining treatment froustaining treatment" means any medical procedure or intervention that, when administered to a qualified patient, serves only to prolong the dying process. (8) "Living will protocol" means a locally deider" means a person who is licensed, certified, or otherwise authorized by the laws of this state to administer health care in the ordinary course of business or practice of a profession. (7) "Life-sighters, law enforcement officers, first responders, emergenc y medical technicians, or other emergency services personnel acting within the ordinary course of their professions. (6) "Health care prove requirements of 509-103. (4) "Department" means the department of public health and human services provided for in 2-15-2201. (5) "Emergency medical services personnel" means paid or volunteer firef has primary responsibility for the treatment and care of the patient. (2) "Board" means the Montana state board of medical examiners. (3) "Declaration" means a document executed in accordance with thttorney for Health Care Form. 50-9-102. Definitions. As used in this chapter, the following definitions apply: (1) "Attending physician" means the physician selected by or assigned to the patient, whoAttorney for Health Care is based on Title 50 Chapter 9 Section 50-9102 et. Seq. of the Montana Statutes. The following are useful excerpts from the Montana Statutes relating to the Montana Power of Aealth Care & Declaration This package contains (1) Information and Instruction for Montana Power of Attorney for Health Care; (2) Montana Power of Attorney for Health Care Form. This Montana Power of ith a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Montana Power of Attorney for Hour particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed we. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits y made or are provided as to their suitability for any specific purpose or as to their legal effect or completene ss. [_]These forms are not intended and are not a substitute for legal and/or tax adviclth Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have beenMontana Advance Health Care Directive This package contains both a Montana Power of Attorney for Health Care and a Montana Living Will. Together these forms are also sometimes known as an Advance Hea Montana