A Montana advance directive is a form that can be used to authorize someone to make healthcare-related decisions on behalf of someone else. The directive asks the principal to provide direction regarding their preferences for life-prolonging treatments or breathing/feeding tubes. The designated representative is also legally authorized to access the principal’s medical records.
Statutory Form
- Statute: § 50-9-103
- Download: Adobe PDF
DECLARATION
If I should have an incurable or irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician or attending advanced practice registered nurse, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician or attending advanced practice registered nurse, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
Signed this [DAY] day of [MONTH], 20[XX].
Signature ____________________________________
City, County, and State of Residence [CITY, COUNTY, STATE]
The declarant voluntarily signed this document in my presence.
Witness _____________________________________
Address [ADDRESS, STREET, CITY, COUNTY, STATE]
Witness _____________________________________
Address [ADDRESS, STREET, CITY, COUNTY, STATE]
DECLARATION
If I should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician or attending advanced practice registered nurse, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I appoint [NAME] or, if that person is not reasonably available or is unwilling to serve, [NAME], 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, pursuant 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 or attending advanced practice registered nurse, pursuant to the Montana 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] day of [MONTH], 20[XX].
Signature ____________________________________
City, County, and State of Residence [CITY, COUNTY, STATE]
The declarant voluntarily signed this document in my presence.
Witness _____________________________________
Address [ADDRESS, STREET, CITY, COUNTY, STATE]
Witness _____________________________________
Address [ADDRESS, STREET, CITY, COUNTY, STATE]
Name and address of designee.
Name [NAME]
Address [ADDRESS, STREET, CITY, COUNTY, STATE]
Adobe PDF