Durable Power Of Attorney For Health Care And Medical Treatment (Page 2 of 2) in pdf

Durable Power Of Attorney For Health Care And Medical Treatment Page 2

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 _______________, 20____.

____________________________________________

(Signature)

STATE OF MONTANA

)

: ss

COUNTY OF ___________ )

Subscribed, sworn to and acknowledged before me this __________day of

_______________________, 20_____.

(Notarial Seal)

(Signature of Notary)

(Printed Name)

NOTARY PUBLIC FOR THE STATE OF MONTANA

Residing at:

My Commission Expires:

Medical POA

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Durable Power Of Attorney For Health Care And Medical Treatment Page 2