Montana Advance Directive Form

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A Montana advance directive is a document that lets a person designate a health care agent to make decisions on their behalf and to outline special directions for treatment. The form only becomes available for use after the patient has been confirmed to be incapacitated. In such an event, the agent selected would be able to make health care decisions for the patient in accordance with their defined medical wishes.

Table of Contents

Laws

Statute – Title 53, Chapter 21 (Mental Health Care Advance Directives)

Signing Requirements (§ 509103(1), § 53-21-1304(2)(d)) – Two (2) witnesses. The principal should also have their signature acknowledged before a notary public if they intend on delegating powers to the agent regarding mental health treatment.

State Definition (§ 53-21-1302(3)) – “Directive” means a mental health care advance directive or any part of a mental health care advance directive.

Versions (6)


Bozeman Health

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Montana Attorney General

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Montana Peer Network

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Montana Disability Rights

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Spanish (Español) Version

Download: Adobe PDF

 

 

 


St. Peter’s Health

Download: Adobe PDF

 

 

Registry

After an individual completes an advance directive it is recommended to be registered with the declaration registry (§ 50-9-501). This can be completed by filling-in the Consumer Registration Agreement (Spanish (Español) Version) and send to the following address:

Office of Consumer Protection P.O. Box 201410 Helena, MT 59620-1410

After approximately 2-3 weeks the Office of Consumer Protection will send back the form along with wallet cards and other supplements. This is a 100% free service provided by the State of Montana.

How to Write

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Introduction

(1) Printed Name Of Montana Declarant. You may use this document to act as a Montana Declarant issuing direct medical instructions, a Montana Principal appointing a Health Care Representative to speak to Physicians in this state for you (when you are unable to), or both. Begin by printing your full name as the potential Montana Patient issuing his or her directives in the first declaration made by this document.

Section 1. Terminal Conditions (Living Will)General Treatment Directions

Select Item 2 Or Item 3

(2) Provide No Directions At This Time. As mentioned earlier, you have a choice regarding the purpose of this issue. If you are only using this paperwork to appoint a Health Care Representative and do not wish to provide treatment instructions to Montana Physicians, then select the first statement’s checkbox to indicate this.

(3) Directions To Withdraw Or Withhold Treatment. To demonstrate the intent to instruct Montana Physicians to refrain from administering life-support when your body can no longer survive independently, select the second statement in this section.

Additional Declaration For Treatment Withdrawals Or Withholdings

Select Any Or All Items You Wish Applied

(4) Comfort Care Treatment. A list of directives has been supplied so that you may further define to Montana Physicians specifics behind your denial of life-prolonging treatment. You can use the first statement of this list to declare that you wish all treatment goals followed to be placed in the context of maintaining your dignity, keeping you comfortable, and (if possible) relieving you of pain.

(5) Refuse Artificial Hydration. Medical conditions that prevent you from safely drinking water can cause dehydration that leads to death. Montana Physicians will thus prioritize keeping their Patients hydrated even if through an I.V. or a tube. You can refuse to accept the delivery of water to your system using artificial methods by selecting the second checkbox statement.

(6) Deny Medically Inserted Nutrition. In some medical conditions that prevent you from intaking food or even absorbing nutrients using your gastrointestinal tract. Since this can quickly lead to dangerous deficiencies in vitamins, minerals, and other needed nutrients Montana Doctors will wish to feed you even through a tube or an I.V. To deny this treatment, select the third checkbox.

(7) Antibiotics Directive. Antibiotics may be needed to prolong your life if you are incapacitated and suffering an incurable medical condition. If you do not approve of antibiotics administered strictly for this reason, then select the appropriate checkbox statement.

(8) Separate Montana Declarant Requests. The option to continue with personalized health care directions, requests, or limits to the Agent’s principal powers is available. You may draw up a separate document to address the matters that concern you directly and in your own voice. If doing so, make sure to inform future Reviewers to seek this attachment by marking the “Yes” box. If not, then confirm to future Reviewers that no attachment to this specific form has been created.

2. Chronic Illness Or Serious Disability

(9) Diagnosis. If you have a chronic illness, disability, or medical condition that will not cause immediate death, it may confuse a future examination when you are rendered unconscious and require medical care for a significant medical event (i.e., an accident, contracting a disease, etc.). Use the provided area in the second section to identify any chronic medical conditions that you currently suffer from (regardless of whether you are receiving treatment).

(10) Consult My Physician. In order for future Montana Health Care Staff to be well-informed of your medical condition, they should have the ability to consult with your current Physician. Present his or her name and contact telephone number for this goal to be met.

(11) Special Directions. You can include any special directions regarding your preferred medical treatment of your chronic condition(s) should attention be needed. This discussion can include preferred medications and/or Medical Facilities.

3. Health Care Representative (Power Of Attorney For Health Care

(12) Montana Health Care Representative. Regardless of whether you have specified your medical preferences, this directive package offers the opportunity to appoint a Health Care Representative to direct Montana Doctors on your medical preferences. Indicate if you will take advantage of this option by selecting the “Yes” box or select the “No” box if you will intentionally refrain from naming a Montana Health Care Representative at this time.

A. Primary Representative

(13) Print Representative’s Full Name. It will be assumed by Reviewers of this paperwork that you have had a frank and decisive discussion on this topic with your Health Care Representative. Print his or her name to complete the statement provided.

(14) Representative’s Address. The permanent mailing address where your Montana Health Care Representative can be reached must be included with this appointment.

(15) Telephone Numbers Of Montana Health Care Representative. It is important that Medical Professionals in this state be able to reach your Montana Health Care Representative quickly and directly when needed. To this end, dispense his or her current telephone numbers. Make sure these numbers remain up-to-date while this document is in effect.

B. Alternate Representative

(16) Printed Name Of First Alternate Agent. If you have named a Montana Health Care Representative, then it would be wise to also name a couple of Alternate Agents that can be approached (successively) to assume this appointment in case your preferred Montana Health Care Representative’s authority has been revoked before a new appointment, he or she is unwilling/unable, or becomes a separated/divorced spouse. Provide the full name of the first person who should be approached to replace your preferred Montana Health Care Representative (if needed) in area 1 then continue down the column to present his or her contact information.

(17) First Montana Alternate Agent Contact Details.

(18) Second Montana Alternate Agent Name. In addition to the First Alternate Agent, you may name a Second Alternate Agent who can be used to replace both the previous Agents should they be unable or unwilling to act as your Health Care Representative in Montana. Produce the full name of the Party who can take over this role under these circumstances. Make sure he or she is certain of accepting this responsibility since your Second Alternate Agent will be approached as a last resort when Montana Doctors seek your medical directives delivered through your appointment.

(19) Contact Information For Second Contact Information.

4. Signing And Witnessing This Advance Directive

(20) Montana Principal Signature Date.

(21) Montana Declarant Signature. In order to issue your declarations and/or your Montana Health Care Representative appointment, you will need to sign your name before two Witnesses and a Notary Public. Quite a few states require that both these options be used to verify that your signature was made while you are able to comprehend your action.

(22) Printed Name. Once you have signed your name, print it as well.

(23) Montana Principal Or Declarant Address. The information needed to contact (and identify you) should be included with your signature beginning with a record of your full address.

(24) Phone Numbers Of Montana Principal Or Declarant.

B.  Ask For Witnesses To Read And Sign

(25) Witness 1 Signature and Signature Dates. Montana requires that either two adult Witnesses and a licensed Notary Public watch you sign this form then testify to that act. Each witness must find and fill out one of the Witness signatures lines by signing it and recording the date.

(26) Witness 1 Permanent Mailing Addresses. Both Witnesses should be prepared to deliver their printed names and mailing addresses. This will enable future contact by any Reviewers seeking to verify the conditions your signature was provided.

(27) Witness 2 Signature And Signature Date

(28) Witness 2 Permanent Mailing Address.

C. Notarizing This Document

(29) Montana Declarant Signature Notarization. A Notary Public whose license is recognized by the State of Montana must also verify that your signature was provided deliberately by subjecting the signed form to the notarization process. The notary will return the notarized directive after completing Section C.

5. Special Directions

A. Spiritual Preferences

(30) Religion And Faith Community. An additional section of this directive enables you to inform Reviewers of information that may not directly relate to your medical treatment preferences but are considered relevant. For instance, if there are religious restrictions or requirements for your environment, diet, and medical care if hospitalized, then it would be wise to present your religion and the name of the community where you practice (i.e., the name of a congregation).

(31) Contact Person. If your spiritual community has set up a Party to receive requests for aid from one of its Members experiencing a serious medical event or end-of-life event, then document this Party’s full name.

(32) Spiritual Support. Indicate if you wish spiritual support by marking the box “Yes” or if you wish to waive this request by marking the “No” box.

B Where I would Like To Be When I Die

(33) End-Of-Life Location. If you have a preference on where an end-of-life event should occur, then select this location from the checkboxes provided. Notice that the fourth option allows you to name a specific place if it is not one of the choices provided.

C. Donation Of Organs At My Death

(34) Deny Donating Any Body Parts, Organs, Or Tissues. As the Montana Declarant, you have the right to make sure your body parts, organs, and other tissues are not made into anatomical gifts. To take advantage of this right select the appropriate statement at the start of Section C.

(35) Donate Your Entire Body. If you wish to declare that your body should be donated as a whole (if needed) upon death then, select the second option. 

(36) Authorized Donations Of Body Parts, Organs, Or Tissues. The third option presented enables you to choose specific body parts that you authorize to be made into anatomical gifts upon death. You may also select Other(s) if your preference is not one of the presented choices.

D. After-Death Care

(37) Directions For Your Body Post Death. You can present additional directions for your body such as a list of specific organs and body parts that you authorize for donation, who should handle your funeral arrangements, what funeral arrangements have been made, and any specific preferences for the disposition of your body using the space provided.

E. Additional Directions

(38) Additional Directions. Any topics left uncovered in this additional area must be discussed to be considered part of your directives. Thus, make use of the available area to further explain any of the choices you presented above (i.e., contact information for your spiritual needs or any specific hospice arrangements you have made, or wish made). You can continue on an attachment if more room is required

Approving This Document 

(39) Montana Declarant Signature. These special or additional instructions to define the Montana Principal or Declarant’s wishes after death must be signed by him or her to place them in effect.

(40) Montana Declarant Signature Date.

F. Distributing This Advance Directive

(41) Distribution Acknowledgment. If you intend to distribute this paperwork, then indicate this by selecting the “Yes” box and continue to supply some crucial contact information otherwise, simply mark “No” to verify that you will not formally distribute copies of this document to other Parties.

(42) Physician Information. Naturally, it is recommended that you make sure all relevant Parties have a copy of your completed directive (and that it is kept up to date). To this end, name the Physician or Physician’s Office that will be given a copy of this directive and provide the information needed to reliably contact him or her.

(43) Hospital Information. The full name of the Hospital where you receive care (or intend to) should be dispensed along with its mailing address. If there is a specific phone line that should be used to contact a Medical Professional familiar with this document and your medical history, this too may be presented.

(44) Family Member Relationship. It is strongly recommended that at least one (trusted) Person in your family be kept informed of this directive as well as receive a copy for storage and reference. Provide a description of how this Recipient is related to you.

(45) Family Member Information. The full name, complete address, current home telephone number, and current work phone number where the Family Member holding a copy of your directives can be contacted should be documented.

(46) Clergy Information. If you intend to deliver a copy of your Montana health care preferences to your Clergy then make sure to document the Recipient Clergy Member’s name and contact details. 

 

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