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Montana ss: ___________________________ Name: ____________________________ Address: ___________________________ ______________________________ Address: Address: ______________________________________ ______________________________________ Name and address of designee(s). Name: ____________________________ Addre presence. ______________________________________ ______________________________________ (Witness Signature) (Witness Signature) Print Name: Print Name: ______________________________________ ________________________, 20____ Signature. ___________________________________________ City, County, and State of Residence ______________________________ The declarant voluntarily signed this document in mya Rights of the Terminally Ill Act, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain. Signed this ______day of _______rsuant to the Montana Rights of the Terminally Ill Act. If the individual I have appointed is not reasonably available or is unwilling to serve, I direct my attending physician, pursuant to the Montan___________________ to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pue decisions regarding my medical treatment, I appoint ____________________________________________________ or, if he or she is not reasonably available or is unwilling to serve, ______________________ble condition that, 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 makhase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care & Declaration If I should have an incurable and irreversiould also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purcyou and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You shompleteness. [_]These forms are not intended and are not 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 ow for form): [_] These forms are provided "as is" and no 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 c-9-203. (3) A declaration that designates another individual to make decisions governing the withholding or withdrawal of life-sustaining treatment may, but need not, be in the following form (see belattending physician and other health care providers shall 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 50ed by the attending physician to be in a terminal condition and no longer able to make decisions regarding administration of life-sustaining treatment. (2) When the declaration becomes operative, the e declarant's medical record. 50-9-105. When declaration operative. (1) A declaration becomes operative when: (a) it is communicated to the attending physician; and -2- (b) the declarant is determinnding physician is informed of it before the qualified patient is in need of life-sustaining treatment. (2) The attending physician or other health care provider shall make the revocation a part of th at the earliest opportunity. A revocation communicated to a person other than the attending physician, emergency medical services personnel, or a health care provider is not effective unless the atte to the revocation. A health care provider or emergency medical services personnel witnessing a revocation shall act upon the revocation and shall communicate the revocation to the attending physiciand in any manner, without regard to mental or physical condition. A revocation is effective upon its communication to the attending physician or other health care provider by the declarant or a witnesstreatment, will, in the opinion of the attending physician, result in death within a relatively short time. 50-9-104. Revocation of declaration. (1) A declarant may revoke a declaration at any time antory or insular possession subject to the jurisdiction of the United States. (14) "Terminal condition" means an incurable or irreversible condition that, without the administration of life-sustaining nd current declaration 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 terridesign, adopted by a written, formal understanding of the local community emergency medical services agencies and licensed hospice and home health agencies, that signifies and certifies that a valid aeen determined by the attending physician to be in a terminal condition. (12) "Reliable documentation" means a standardized, statewide identification card or form or a necklace or bracelet of uniform Title 37, chapter 3, to practice medicine in this state. (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 btate, trust, partnership, association, joint venture, government, governmental subdivision or agency, or any other legal or commercial entity. -1- (10) "Physician" means an individual licensed undertive care to and withholding life-sustaining treatment from a qualified patient under 50-9-202 by emergency medical service personnel. (9) "Person" means an individual, corporation, business trust, esying process. (8) "Living will protocol" means a locally developed, community-wide method or a standardized, statewide method developed by the department and approved by the board, of providing palliacourse of business or practice of a profession. (7) "Life-sustaining treatment" means any medical procedure or intervention that, when administered to a qualified patient, serves only to prolong the dordinary course of their professions. (6) "Health care provider" means a person who is licensed, certified, or otherwise authorized by the laws of this state to administer health care in the ordinary cy medical services personnel" means paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, or other emergency services personnel acting within the Declaration" means a document executed in accordance with the requirements of 509-103. (4) "Department" means the department of public health and human services provided for in 2-15-2201. (5) "Emergenns the physician selected by or assigned to the patient, who has primary responsibility for the treatment and care of the patient. (2) "Board" means the Montana state board of medical examiners. (3) "from the Montana Statutes relating to the Montana Power of Attorney for Health Care Form. 50-9-102. Definitions. As used in this chapter, the following definitions apply: (1) "Attending physician" meawer of Attorney for Health Care Form. This Montana Power of Attorney for Health Care is based on Title 50 Chapter 9 Section 50-9102 et. Seq. of the Montana Statutes. The following are useful excerpts Information and Instructions Montana Power of Attorney for Health Care & Declaration This package contains (1) Information and Instruction for Montana Power of Attorney for Health Care; (2) Montana Po Montana