Oklahoma § 63-3111.5 - Health Care Power of Attorney form

§ 63-3111.5. Health Care Power of Attorney form

The following form may, but need not, be used to create a power

of attorney for health care. The other sections of this act govern

the effect of this form or any other writing used to create a power

of attorney for health care. An individual may complete or modify

all or any part of the following form to the extent consistent with

subsection B of Section 3111.3 of this title:

HEALTH CARE POWER OF ATTORNEY

You have the right to give instructions about your own health

care. You also have the right to name someone else to make health

care decisions for you. This form lets you do either or both of

these things. If you use this form, you may complete or modify all

or any part of it. You are free to use a different form.

This form is a power of attorney for health care that lets you

name another individual as agent to make health care decisions for

you if you become incapable of making your own decisions or if you

want someone else to make those decisions for you now even though

you are still capable. You may also name an alternate agent to act

Oklahoma Statutes - Title 63. Public Health and Safety

for you if your first choice is not willing, able, or reasonably

available to make decisions for you. Unless related to you, your

agent may not be an owner, operator, or employee of a residential

long-term health care institution at which you are receiving care.

Unless the form you sign limits the authority of your agent,

your agent may make all health care decisions for you. This form

has a place for you to limit the authority of your agent. You need

not limit the authority of your agent if you wish to rely on your

agent for all health care decisions that may have to be made. If

you choose not to limit the authority of your agent, your agent will

have the right to:

1. Consent or refuse consent to any care, treatment, service,

or procedure to maintain, diagnose, or otherwise affect a physical

or mental condition;

2. Select or discharge health care providers and facilities;

and

3. Sign a do-not-resuscitate consent.

This form does not authorize the agent to make any decisions

directing the withholding or withdrawal of life-sustaining

treatment, nutrition, or hydration, which may only be authorized in

compliance with the Oklahoma Advance Directive Act, except that this

form may authorize the agent to sign a do-not-resuscitate consent.

After completing this form, sign and date the form at the end.

It is required that two other individuals sign as witnesses. These

witnesses must be at least 18 years old and not related to you or

named to inherit from you. Give a copy of the signed and completed

form to your physician, to any other health care providers you may

have, to any health care facility at which you are receiving care,

and to any health care agents you have named. You should talk to

the person you have named as agent to make sure that he or she

understands your wishes and is willing to take the responsibility.

You have the right to revoke this power of attorney for health

care or replace this form at any time.

POWER OF ATTORNEY FOR HEALTH CARE

1. DESIGNATION OF AGENT: I designate the following individual

as my agent to make health care decisions for me:

___________________________________________________________________

(name of individual you choose as agent)

___________________________________________________________________

(address)

(city)

(state)

(zip code)

___________________________________________________________________

(home phone)

(work phone)

OPTIONAL: If I revoke my agent’s authority or if my agent is

not willing, able, or reasonably available to make a health care

decision for me, I designate as my first alternate agent:

___________________________________________________________________

(name of individual you choose as first alternate agent)

Oklahoma Statutes - Title 63. Public Health and Safety

___________________________________________________________________

(address)

(city)

(state)

(zip code)

___________________________________________________________________

(home phone)

(work phone)

OPTIONAL: If I revoke the authority of my agent and first

alternate agent or if neither is willing, able, or reasonably

available to make a health care decision for me, I designate as my

second alternate agent:

___________________________________________________________________

(name of individual you choose as second alternate agent)

___________________________________________________________________

(address)

(city)

(state)

(zip code)

___________________________________________________________________

(home phone)

(work phone)

2. AGENT’S AUTHORITY: My agent is authorized to make all

health care decisions (not to include the withholding or withdrawal

of life-sustaining treatment, nutrition, or hydration, other than

signing a do-not-resuscitate consent) for me that I could make if I

were able, except as I state here:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

(Add additional sheets if needed.)

3. WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s

authority becomes effective when my attending physician determines

that I am unable to make my own health care decisions unless I mark

the following box. If I mark this box [

], my agent’s authority

to make health care decisions for me takes effect immediately.

_____________

(Initials)

4. AGENT’S OBLIGATION: My agent shall make health care

decisions for me in accordance with this power of attorney for

health care and my other wishes to the extent known to my agent. To

the extent my wishes are unknown, my agent shall make health care

decisions for me in accordance with what my agent determines to be

in my best interest. In determining my best interest, my agent

shall consider the decisions I would have made myself to the extent

known to my agent.

_____________

(Initials)

5. RELIEF FROM PAIN: Except as I state in the following space,

I direct that treatment for alleviation of pain or discomfort be

provided at all times, even if it hastens my death:

________________________________________________________________

________________________________________________________________

6. OTHER WISHES: (If you do not agree with any of the optional

choices above and wish to write your own, or if you wish to add to

Oklahoma Statutes - Title 63. Public Health and Safety

the instructions you have given above, you may do so here.) I

direct that:

___________________________________________________________________

___________________________________________________________________

(Add additional sheets if needed.)

7. EFFECT OF COPY: A copy of this form has the same effect as

the original.

8. SIGNATURES: Sign and date the form here:

_______________________________

______________________________

(date)

(sign your name)

_______________________________

______________________________

(address)

(print your name)

_______________________________

(city)

(state)

State of Oklahoma

County of ________

Subscribed and sworn to before me this ___ day of ______, 20__.

__________________________________

Notary Public

OR

SIGNATURES OF WITNESSES:

First witness

Second witness

______________________________

_______________________________

(print name)

(print name)

______________________________

_______________________________

(address)

(address)

______________________________

______________________________

(city)

(state)

(city)

(state)

______________________________

______________________________

(signature of witness)

(signature of witness)

______________________________

______________________________

(date)

(date)

Added by Laws 2022, c. 136, § 5, emerg. eff. April 29, 2022.

Amended by Laws 2023, c. 154, § 2, emerg. eff. May 1, 2023.