Montana Adult Protective Services Report — Vulnerable Adult Abuse, Neglect, or Exploitation

MONTANA ADULT PROTECTIVE SERVICES REPORT

Vulnerable Adult Abuse, Neglect, Sexual Abuse, or Exploitation

TABLE OF CONTENTS

1. Reporter Information
2. Mandatory-Reporter Status and Statutory Basis
3. Vulnerable Adult Information
4. Alleged Perpetrator(s)
5. Description of Abuse, Neglect, Sexual Abuse, or Exploitation
6. Evidence and Witnesses
7. Risk Assessment and Immediate Safety
8. Prior Reports and Coordination
9. Reporter Certification, Confidentiality, and Immunity
10. Filing Cover Sheet — Where and How to Submit
11. Montana Practice Notes
12. Sources and References

1. REPORTER INFORMATION

1.1. Method of Report: ☐ APS hotline (1-844-277-9300) ☐ DPHHS online portal ☐ Local law enforcement ☐ County attorney ☐ Long-Term Care Ombudsman (1-800-332-2272) ☐ Other: [__________]

1.2. APS Intake / Case No. (if assigned): [________________________________]

2. MANDATORY-REPORTER STATUS AND STATUTORY BASIS

2.1. The reporter is a mandatory reporter under Mont. Code Ann. § 52-3-811 in the following category (check all that apply):

☐ Physician, resident, intern, or physician assistant
☐ Professional or practical nurse
☐ Dentist, chiropractor, optometrist
☐ Medical examiner / coroner
☐ Ambulance attendant / EMT
☐ Member of the staff of a public assistance agency
☐ Mental health professional (psychologist, LCSW, LCPC)
☐ Staff of a roominghouse, retirement home or complex, nursing home, group home, or adult foster care facility
☐ Attorney (subject to attorney-client privilege exceptions)
☐ Peace officer / law enforcement officer
☐ Provider under contract with DPHHS
☐ Department employee acting in an official capacity
☐ Conservator, legal guardian, or representative payee
☐ Permissive reporter (any other person under § 52-3-811)

2.2. Reasonable Cause Statement. The reporter knows or has reasonable cause to suspect that a vulnerable adult, as defined in Mont. Code Ann. § 52-3-803, has been or is being:

☐ Abused (physical, mental, or emotional)
☐ Sexually abused
☐ Neglected (by another or self-neglecting)
☐ Exploited (financial / fiduciary)

2.3. Privilege. No privilege other than the attorney-client privilege excuses this report. The reporter has not relied on any communication privileged under Mont. Code Ann. Title 26, Chapter 1, Part 8 to withhold reportable information.

3. VULNERABLE ADULT INFORMATION

3.1. Legal Name: [________________________________]

3.2. Other Names / Aliases: [________________________________]

3.3. Date of Birth / Age: [__/__/____] — Age [____]

3.4. Sex / Gender: [________________________________]

3.5. Current Location / Address: [________________________________]

3.6. Phone: [________________________________]

3.7. Type of Residence: ☐ Private home ☐ Apartment ☐ Assisted living facility ☐ Nursing facility ☐ Adult foster care ☐ Hospital ☐ Group home ☐ Homeless / unsheltered ☐ Other: [__________]

3.8. Facility / Provider Name (if institutional): [________________________________]

3.9. Basis for "Vulnerable Adult" Status under § 52-3-803 (check all that apply):

☐ Age 60 or older with diminished capacity
☐ Adult with developmental disability
☐ Adult with physical disability impairing self-protection
☐ Adult with cognitive impairment / dementia / Alzheimer's
☐ Adult with serious mental illness
☐ Adult under guardianship / conservatorship
☐ Other condition impairing self-protection: [__________]

3.10. Primary Language / Communication Needs: [________________________________]

3.11. Spouse / Closest Family Member: [________________________________] — Phone: [________________________________]

3.12. Power of Attorney / Guardian / Conservator: [________________________________]

3.13. Primary Care Physician: [________________________________]

4. ALLEGED PERPETRATOR(S)

4.1. Position of Trust or Authority (e.g., facility staff, family caregiver, fiduciary): [________________________________]

4.2. Prior History of Concern (if known): [________________________________]

5. DESCRIPTION OF ABUSE, NEGLECT, SEXUAL ABUSE, OR EXPLOITATION

5.1. Date(s) and Time(s) of Incident(s): [________________________________]

5.2. Location(s) of Incident(s): [________________________________]

5.3. Nature of the Allegation (check all that apply):

☐ Physical abuse (hitting, restraining, rough handling, unexplained injury)
☐ Mental / emotional abuse (threats, intimidation, isolation, humiliation)
☐ Sexual abuse / sexual contact without capacity to consent
☐ Active neglect (caregiver withholds food, medication, hygiene, medical care)
☐ Passive neglect / self-neglect (adult unable to provide for own needs)
☐ Financial exploitation (theft, undue influence, unauthorized transactions, abuse of POA, predatory transfers)
☐ Misuse of property or fiduciary position
☐ Abandonment

5.4. Narrative Description (write in plain, factual language; attach additional pages as needed):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

5.5. Observed Injuries or Conditions (location, size, color, stage of healing):

[____________________________________________________________]

5.6. Statements by the Vulnerable Adult (verbatim where possible):

"[____________________________________________________________]"

5.7. Statements by Caregivers / Family / Others:

[____________________________________________________________]

5.8. Financial-Exploitation Specifics (if applicable):

6. EVIDENCE AND WITNESSES

6.1. Physical Evidence Preserved or Photographed: ☐ Photographs ☐ Soiled clothing ☐ Medication bottles ☐ Bank statements ☐ Checks ☐ Texts/voicemails ☐ Other: [__________]

6.2. Medical Records Reviewed: [________________________________]

6.3. Witnesses:

6.4. Documents Attached: ☐ Photographs ☐ Clinical notes ☐ Bank/financial records ☐ Power of attorney ☐ Police report ☐ Prior APS letter ☐ Other: [__________]

7. RISK ASSESSMENT AND IMMEDIATE SAFETY

7.1. Is the vulnerable adult in immediate danger? ☐ Yes — 911 called at [__:__ AM/PM] on [__/__/____] ☐ No

7.2. Current location of the alleged perpetrator: [________________________________]

7.3. Does the alleged perpetrator have ongoing access to the adult? ☐ Yes ☐ No

7.4. Capacity Concerns. The vulnerable adult ☐ does ☐ does not appear to have decisional capacity sufficient to consent to or refuse services. Documentation: [________________________________]

7.5. Protective Measures Already Taken:

☐ Hospital admission / medical treatment
☐ Welfare check by law enforcement
☐ Order of protection sought (Mont. Code Ann. § 40-15-201)
☐ Bank fraud alert / account freeze
☐ Notification to facility administrator
☐ Notification to family / POA
☐ Other: [__________]

7.6. Recommended APS Response Priority: ☐ Emergency (within 24 hours) ☐ Priority (within 5 business days) ☐ Routine

8. PRIOR REPORTS AND COORDINATION

8.1. Have you previously reported concerns about this adult? ☐ Yes ☐ No — Date / agency / outcome: [________________________________]

8.2. Other agencies notified or to be notified (check all that apply):

☐ Local law enforcement — agency: [__________], report no. [__________]
☐ County attorney — county: [__________]
☐ Long-Term Care Ombudsman (1-800-332-2272) — required where facility resident
☐ DPHHS Quality Assurance Division (facility complaint)
☐ Adult Resource Alliance / Area Agency on Aging
☐ Tribal social services (if applicable)
☐ Office of the State Public Defender / Court (if guardianship pending)
☐ Bank / financial institution fraud unit
☐ Veterans Affairs (if VA beneficiary)

8.3. Facility-Resident Note. Per Mont. Code Ann. § 52-3-811, a report involving a resident of a long-term care facility must be made to BOTH (a) the Long-Term Care Ombudsman AND (b) DPHHS.

9. REPORTER CERTIFICATION, CONFIDENTIALITY, AND IMMUNITY

9.1. Good-Faith Certification. I certify that the foregoing information is true and correct to the best of my knowledge and is reported in good faith pursuant to Mont. Code Ann. § 52-3-811.

9.2. Statutory Immunity (§ 52-3-814). I submit this report with the understanding that I am immune from civil or criminal liability that might otherwise be imposed as a result of the report unless the report is false in a material respect and I acted in bad faith or with malicious purpose.

9.3. Confidentiality (§ 52-3-813). I understand that this report and the identity of the reporter are confidential and may be disclosed only as authorized by statute (e.g., to the department, law enforcement, the county attorney, the courts, and the long-term care ombudsman).

9.4. No Retaliation. I understand that retaliation against a reporter is prohibited and that the immunity provision protects reports made in good faith without regard to whether the underlying allegation is ultimately substantiated.

9.5. HIPAA / 42 CFR Part 2. Reporting protected health information to APS pursuant to Mont. Code Ann. § 52-3-811 is permitted under 45 C.F.R. § 164.512(c) (disclosures about victims of abuse, neglect, or domestic violence) and does not require patient authorization.

Date: [__/__/____]

[________________________________]

Reporter Signature

Print Name: [________________________________]

Title: [________________________________]

10. FILING COVER SHEET — WHERE AND HOW TO SUBMIT

10.1. Primary — Statewide APS Intake (DPHHS Senior & Long-Term Care Division):

• Hotline: 1-844-277-9300 (24/7)
• Online: https://dphhs.mt.gov/SLTC/APS/
• Mail: Adult Protective Services, DPHHS, P.O. Box [verify current], Helena, MT 59604

10.2. Long-Term Care Ombudsman (mandatory parallel report for facility residents):

• State Ombudsman: 1-800-332-2272
• Regional Ombudsman / Area Agency on Aging: 1-800-551-3191

10.3. Law Enforcement:

• Emergency: 911
• Local agency: [________________________________]

10.4. County Attorney (where applicable):

• County: [__________], Phone: [__________]

10.5. DPHHS Quality Assurance Division (Facility Licensing Complaints):

• Online complaint: https://dphhs.mt.gov/oig/QADComplaint
• Phone: [verify current QAD complaint number]

10.6. Suspected Financial Exploitation Notifications:

• Adult's bank/credit union fraud unit
• Mont. Securities Commissioner / State Auditor (if securities involved)
• Internet Crime Complaint Center (IC3) for online fraud
• Federal Trade Commission (identity theft): https://www.identitytheft.gov

11. MONTANA PRACTICE NOTES

• Statute. The Montana Vulnerable Adult Prevention of Abuse Act is codified at Title 52, Chapter 3, Part 8. Key sections: § 52-3-803 (definitions), § 52-3-804 (DPHHS duties), § 52-3-811 (mandatory reporters), § 52-3-812 (content), § 52-3-813 (confidentiality), § 52-3-814 (immunity).
• 2023 expansion. SB 34 (2023) expanded both the definition of "vulnerable adult" and the list of mandatory reporters; verify the current statutory text in the most recent MCA publication before relying on older summaries.
• No statutory bright-line deadline. Unlike Mont. Code Ann. § 41-3-201 (child abuse — "promptly"), Part 8 does not enumerate a clock-hour deadline. Best practice is an immediate oral report (hotline / 911 if emergent) followed by a written report within 24-72 hours.
• What to report (§ 52-3-812). Identity of vulnerable adult, identity of perpetrator (if known), nature/extent of abuse/neglect/exploitation, prior similar incidents, family composition, and any other helpful information.
• Self-neglect. Montana's APS responds to self-neglect by competent adults; services are voluntary unless capacity is impaired and a guardianship/conservatorship is sought.
• Criminal cross-reference. Mont. Code Ann. § 45-6-333 criminalizes exploitation of an older person (60+) or person with developmental disability; penalties scale with the value of property exploited and may be charged in addition to APS civil intervention.
• Civil remedies. A vulnerable adult may pursue civil claims for conversion, breach of fiduciary duty, undue influence, and constructive trust; § 72-3-1011 may permit accelerated proceedings against a fiduciary.
• Tribal coordination. When the vulnerable adult is a member of a Montana tribe and resides on a reservation, coordinate with tribal social services and BIA; jurisdictional issues may apply under Public Law 280 / 25 U.S.C. § 1911.
• HIPAA. Reporting under § 52-3-811 fits within 45 C.F.R. § 164.512(c) (abuse, neglect, domestic violence). Document the date, recipient, and statutory basis of any PHI disclosure.
• Penalties for failure to report. While Part 8 does not enumerate a uniform criminal penalty, professional licensure boards may discipline failure to report (e.g., Board of Medical Examiners, Board of Nursing); professionals may also face civil liability for foreseeable continued harm.
• Retain a copy. Keep the written report secured separately from the patient chart for at least the longer of (a) the period required by professional regulation or (b) seven years.

12. SOURCES AND REFERENCES

• Montana DPHHS — Adult Protective Services: https://dphhs.mt.gov/SLTC/APS/
• Montana Long-Term Care Ombudsman: https://dphhs.mt.gov/sltc/aging/longtermcareombudsman/
• Montana Vulnerable Adult Prevention of Abuse Act (Title 52, Chapter 3, Part 8): https://mca.legmt.gov/bills/mca/title_0520/chapter_0030/part_0080/sections_index.html
• Mont. Code Ann. § 52-3-811 (Reports): https://mca.legmt.gov/bills/mca/title_0520/chapter_0030/part_0080/section_0110/0520-0030-0080-0110.html
• Mont. Code Ann. § 52-3-813 (Confidentiality): https://mca.legmt.gov/bills/mca/title_0520/chapter_0030/part_0080/section_0130/0520-0030-0080-0130.html
• Mont. Code Ann. § 52-3-814 (Immunity): https://mca.legmt.gov/bills/mca/title_0520/chapter_0030/part_0080/section_0140/0520-0030-0080-0140.html
• Mont. Code Ann. § 45-6-333 (Exploitation of an older person)
• Montana DPHHS Vulnerable Adult Statute (2025 update): https://dphhs.mt.gov/assets/oig/MontanaVulnerableAdultPreventionofAbuseAct_updated2025.pdf
• DPHHS Office of Inspector General — Quality Assurance Division Complaints: https://dphhs.mt.gov/oig/QADComplaint
• 42 U.S.C. § 1397j et seq. (Elder Justice Act)
• 45 C.F.R. § 164.512(c) (HIPAA permitted disclosures — victims of abuse)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters retain their statutory duties whether or not this template is used. If a vulnerable adult is in immediate danger, call 911 first.