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Oklahoma Durable Power of Attorney for Health Care Form

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Oklahoma Durable Power of Attorney for Health Care Form is required when appointing a loved one (as per Tit. 63 §3101) to make medical decisions on his or her behalf when and if rendered unable to communicate or incapacitated. The principal will have to set some time aside to consult with his or her chosen agent and, if appropriate, a medical professional before sitting down to set his or her directives on paper. Ultimately, the elected agent will have to act as the principal’s voice when he or she is unable to provide medically related decisions (i.e. vegetative state, unconscious, etc.) therefore, it is imperative such an agent knows the principal’s preferences well enough to act even in an unforeseen scenario.

Laws – § 63-3101.4

Living Will – Create explicit instructions as to your end of life treatment options to doctors and medical staff if you should become incapacitated with no cure or recourse.

Advance Directive – Combines the living will and power of attorney in one (1) document. After completing keep the wallet card in the patient’s wallet.

Durable (Financial) Power of Attorney – Like a durable POA for healthcare, an agent is appointed to handle your affairs for you. However, in this case, the representative will manage your finances when you become incapacitated.

How to Write

1 – Obtain The Paperwork On This Page To Grant Durable Health Care Powers

Find the buttons accompanying the image on this page. The template can be obtained by clicking on the button designated with the file type you prefer. For instance, if you are using Adobe, click on the “PDF” button. Make sure to read the introductory “Notice” before filling out this document.

2 – Present An Introduction Of The Principal And Health Care Attorney-in-Fact

The beginning of this document will present three blank areas in a declaration statement. Use the first blank area to document the Full Name and Complete Address of the Principal determined to grant Health Care Authority to an Attorney-in-Fact. The second blank area will call for the Legal Name And Address of the Health Care Attorney-in-Fact or Agent to be recorded accurately. This individual will have the Principal Power delivered in this document upon the Date of Effect. The final available area will refer to the Alternate Agent’s Name and Address. This person will only be assigned Principal Powers if the Agent does not, cannot, or will not utilize Principal Powers.

4 – Assign the Primary Health Care Powers The Agent Should Have

Due to the nature of these Principal Powers, it is strongly suggested the Principal have a very frank and specific discussion with the intended Health Care Attorney-in-Fact or Agent regarding his or her expectations of delivering any such Powers. Once this task has been completed, the Principal will need to give the Agent the right to act on his or her behalf regarding Medical Decisions, Treatment, and Care. This Principal Approval will occur through the Principal’s initials placed in the appropriate items listed in “I. Grant Of Health Care Powers.”

The Principal should locate the statement “1. If I am Unable To Decide Or Speak For Myself…” then initial each statement defining a Power the Health Care Attorney-in-Fact can wield on his or her behalf. Statement “a” will provide the Health Care Attorney-in-Fact the Principal Power to make Medical Decisions in general (with the few exceptions listed), Statement “b” grants the Agent with the Authority to choose Health Care Providers for the Principal, Statement “c” delivers the right to choose where the Principal lives if his or her Health Care is involved, Statement “d” allows the Agent to access, review, and disseminate the Principal’s Medical Records with the same Authority the Principal has, Statement “e” delegates the Authority to choose a Hospice for the Principal to the Agent, and Statement “f” shall grant all these Powers to the Agent. If the Principal wishes to grant only some of these Powers, he or she should only initial the blank lines corresponding to those Powers. If the Principal would like to delegate all these Powers, then he or she should only initial Statement “f”

5 – Discuss The Principal Preferences

Section “II. Additional Guidance And Information” shall allow the Principal an opportunity to declare his or her preferences in certain scenarios or circumstances. This section is not mandatory however can be a valuable reference for the Agent. Several statements have been provided with some blank lines. If there is not enough room for one or more of these items, the Principal Preferences may be continued on a separate document, labeled, dated, and signed then, attached to this paperwork.

If the Principal has any goals regarding his or her Health care they may be addressed in the area labeled “a. My Goals For My Health Care.” The Principal may feel free to discuss how he or she expects any treatment to go, whether he or she expects artificial nutrition/hydration, and/or pain management when in a medical event. The Principal is not limited to these topics here and may freely discuss at length his or her expectations.   If the Principal has any fears regarding Medical Treatments, the Prolonging of his or her life, Medical Intervention in the face of an Emergency, etc., he or she may document them in “b. My Fears About My Health Care.”In some cases, an individual’s religious beliefs may have a profound effect on what may or may not be done in certain Medical Events. If this issue should be addressed, it may be done in “c. Spiritual Or Religious Beliefs And Traditions.”

If the Principal has any concerns regarding how his or her Medical Treatment will affect his or her family and wishes to state what he or she does and does not want, he or she should attend to Statement “d. My Thoughts About How My Medical Condition Might Affect My Family.”

The Principal may have some preferences regarding where he or she receives Medical Treatment or Health Care. If so, such preferences should be documented in “e. My Thoughts About Living And Receiving Health Care At Home Versus…”

The Principal may have additional instructions that would extend or limit the Health Care Powers the Attorney-in-Fact may wield. Such instructions will need to present before this paperwork is signed, thus any such instructions should be recorded using the space available in the “Special Instructions” section. If more space is required, they may be continued on an attachment.

6 – Document The Event That Shall Put These Powers In Effect

The Powers this paperwork will enable the Principal to appoint to the Health Care Attorney-in-Fact must have a definitive time when they will start being accessible to the Agent. In “III. When Power Becomes Effective,” the Principal may either set these Powers in Effect as soon as this paperwork is signed or set it in Effect automatically when a Physician has declared the Principal incapacitated and this written diagnosis is attached to this paperwork. The Principal should initial the first statement to give the Agent access to Principal Powers when this document is executed or initial the second statement to make these Powers Effective only when he or she is incapacitated and diagnosed as being so by a Physician (in writing).

7 – The Principal Must Supply A Verifiable Signature

Once this paperwork has been set up to the satisfaction of the Principal, he or she should take the time out to review it. When ready, the Principal must sign his or her Name on the blank line labeled “Principal’s Signature” then supply his or her Full Street Address on the next blank line. The Principal Signing must be witnessed by two separate individuals. Each Witness must sign his or her Name on a unique “Witness” line. In addition to two Witnesses, the Principal signing should be Notarized. The area directly below the Witness signatures has been provided for this purpose. Only the Notary Public should fill out the area below the words “State Of Oklahoma”


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