Okla. Stat. tit. 63 § 3111.5
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 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:
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
__________________________________________________
(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)
__________________________________________________
(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) |
__________________________________________________
__________________________________________________
__________________________________________________
(Add additional sheets if needed.)
_______________
(Initials)
_______________
(Initials)
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
(Add additional sheets if needed.)
______________________________ | ______________________________ |
(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) |
Okla. Stat. tit. 63, § 3111.5