Oklahoma Medical Power of Attorney Form

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The Oklahoma medical power of attorney form can be used if you desire to have someone represent you in the chance you cannot speak for yourself. You will be able to select the exact powers your agent will have.

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DURABLE POWER OF ATTORNEY
(WITH HEALTH CARE POWERS ONLY)
NOTICE: The powers granted by this document are broad and sweeping. They are explained in the
Uniform Statutory Form Power of Attorney Act. If you have any questions about these powers, obtain
competent legal advice. Free legal information regarding construction of the powers granted by this
document and completion of this form may be obtained by calling the Legal Services Developer, Aging
Services Division of the Oklahoma Department of Human Services, (405) 522­3069, or your local legal
aid or legal services office. This document authorizes your agent to make medical and other health­care
decisions for you. You may revoke this power of attorney if you later wish to do so.
I
(insert name and address)
appoint
(insert name and address of the person appointed)
as my agent (attorney­in­fact) to act for me in any lawful way with respect to the following initialed subjects.
If my agent is unable or unwilling to serve, I appoint
(insert name and address)
as my alternate agent with the same authority.
Once effective pursuant to section III on the back of this form, this power of attorney will continue to be
effective even though I become disabled, incapacitated, or incompetent, and shall not be affected by
lapse of time.
I. Grant of Health Care Powers
To grant all of the following powers, initial the line in front of (f) and ignore the lines in front of the
other powers.
To grant one or more, but fewer than all, of the following powers, initial the line in front of each power you
are granting.
To withhold a power, do not initial the line in front of it. You may, but need not, cross out each power with
held.
1. If I am unable to decide or speak for myself, my agent has the power to:
Initial
a. Make health and medical care decisions for me, including serving as my representative
under the Oklahoma Do­Not­Resuscitate Act, but excluding signing an advance
directive, making decisions reserved to a health care proxy under an advance directive,
or other life­sustaining treatment decisions.
b. Choose my health care providers.
c. Choose where I live and receive care and support when these choices relate to my health
care needs.
d. Review my medical records and have the same rights that I would have to give my
medical records to other people.
e. Elect hospice treatment.
f. All of the powers listed above.
You need not initial any other lines if you initial line f.
2. It is my intention that my agent’s acts on my behalf are to be honored by my family members and health
care providers as an expression of my legal right to manage my health care. The directions and decisions of
my agent are superior to and shall take precedence over any decision made by any member of my family. To
the extent appropriate, my agent may discuss health care decisions with my family and others to the extent
they are available.
II. Additional Guidance and Information
NOTE: This section, while very helpful to your agent, is optional and choices may be left blank.
a. My goals for my health care:
b. My fears about my health care:
c. My spiritual or religious beliefs and traditions:_____________________
___________________________________
__________________________________
_____________________________________ __________________________________
_____
_____
_____________________________________________
_____________________________________________
_______________________________
__________________________
_____________________
_____________,
________________________________________________________________________________
__________________________________________________________________________
________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____
____
_______________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____,
________________________________________________________________________________
_________________________________________________________________________________________
)
)
)
d. My thoughts about how my medical condition might affect my family:
e. My thoughts about living and receiving health care at home versus in a nursing home or other
institution:
Special Instructions: On the following lines you may give special instructions limiting or extending the
powers granted to your agent.
(Attach additional pages if needed.)
III. When Power Becomes Effective
Please initial one statement below regarding the effective date of this power of attorney.
Initial
This power of attorney is effective immediately and shall continue until it is revoked.
This power of attorney shall be effective when my attending physician determines that I am no longer
able to manage my person. This determination shall be provided in writing and attached to this form.
I agree that any third party who receives a copy of this document may act under it. Revocation of the power of
attorney is not effective as to a third party until the third party learns of the revocation. I agree to indemnify
the third party for any claims that arise against the third party because of reliance on this power of attorney.
Signed:
(Principal’s signature)
City, County, and State of Residence
The principal is personally known to me and I believe the principal to be of sound mind. I am eighteen (18)
years of age or older. I am not related to the principal by blood or marriage, or related to the attorney­in­fact
by blood or marriage. The principal has declared to me that this instrument is his power of attorney granting to
the named attorney­in­fact the power and authority specified herein, and that he has willingly made and exe­
cuted it as his free and voluntary act for the purposes herein expressed.
Witness:
Witness:
STATE OF OKLAHOMA
SS.
COUNTY OF
Before me, the undersigned authority, on this day of 20 personally appeared
(principal), (witness),
and (witness), whose names are subscribed to the foregoing instru
ment in their respective capacities, and all of said persons being by me duly sworn, the principal declared to
me and to the said witnesses in my presence that the instrument is his or her power of attorney, and that the
principal has willingly and voluntarily made and executed it as the free act and deed of the principal for the
purposes therein expressed, and the witnesses declared to me that they were each eighteen (18) years of age or
over, and that neither of them is related to the principal by blood or marriage, or related to the attorney­in­fact
by blood or marriage.
Notary Public
My Commission Expires:
By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsi
bilities of an agent.
OKDHS Pub. No. 99­63 Revised 1/2002
This publication is authorized by the Human Services Commission in accordance with state and federal regulations and printed by
the Oklahoma Department of Human Services at a cost of $1086.40 for 20,000 copies. Copies have been deposited with the
Publications Clearinghouse of the Oklahoma Department of Libraries. DHS offices may request copies on ADM­9 electronic supply
orders. Members of the public may obtain copies by calling 1­877­283­4113 (toll free).

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