{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-3111.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-3111.5","heading":"Health Care Power of Attorney form","body":"The following form may, but need not, be used to create a power\n\nof attorney for health care. The other sections of this act govern\n\nthe effect of this form or any other writing used to create a power\n\nof attorney for health care. An individual may complete or modify\n\nall or any part of the following form to the extent consistent with\n\nsubsection B of Section 3111.3 of this title:\n\nHEALTH CARE POWER OF ATTORNEY\n\nYou have the right to give instructions about your own health\n\ncare. You also have the right to name someone else to make health\n\ncare decisions for you. This form lets you do either or both of\n\nthese things. If you use this form, you may complete or modify all\n\nor any part of it. You are free to use a different form.\n\nThis form is a power of attorney for health care that lets you\n\nname another individual as agent to make health care decisions for\n\nyou if you become incapable of making your own decisions or if you\n\nwant someone else to make those decisions for you now even though\n\nyou are still capable. You may also name an alternate agent to act\n\nfor you if your first choice is not willing, able, or reasonably\n\navailable to make decisions for you. Unless related to you, your\n\nagent may not be an owner, operator, or employee of a residential\n\nlong-term health care institution at which you are receiving care.\n\nUnless the form you sign limits the authority of your agent,\n\nyour agent may make all health care decisions for you. This form\n\nhas a place for you to limit the authority of your agent. You need\n\nnot limit the authority of your agent if you wish to rely on your\n\nagent for all health care decisions that may have to be made. If\n\nyou choose not to limit the authority of your agent, your agent will\n\nhave the right to:\n\n1. Consent or refuse consent to any care, treatment, service,\n\nor procedure to maintain, diagnose, or otherwise affect a physical\n\nor mental condition;\n\n2. Select or discharge health care providers and facilities;\n\nand\n\n3. Sign a do-not-resuscitate consent.\n\nThis form does not authorize the agent to make any decisions\n\ndirecting the withholding or withdrawal of life-sustaining\n\ntreatment, nutrition, or hydration, which may only be authorized in\n\ncompliance with the Oklahoma Advance Directive Act, except that this\n\nform may authorize the agent to sign a do-not-resuscitate consent.\n\nAfter completing this form, sign and date the form at the end.\n\nIt is required that two other individuals sign as witnesses. These\n\nwitnesses must be at least 18 years old and not related to you or\n\nnamed to inherit from you. Give a copy of the signed and completed\n\nform to your physician, to any other health care providers you may\n\nhave, to any health care facility at which you are receiving care,\n\nand to any health care agents you have named. You should talk to\n\nthe person you have named as agent to make sure that he or she\n\nunderstands your wishes and is willing to take the responsibility.\n\nYou have the right to revoke this power of attorney for health\n\ncare or replace this form at any time.\n\nPOWER OF ATTORNEY FOR HEALTH CARE\n\n1. DESIGNATION OF AGENT: I designate the following individual\n\nas my agent to make health care decisions for me:\n\n___________________________________________________________________\n\n(name of individual you choose as agent)\n\n___________________________________________________________________\n\n(address) (city) (state) (zip code)\n\n___________________________________________________________________\n\n(home phone) (work phone)\n\nOPTIONAL: If I revoke my agent’s authority or if my agent is\n\nnot willing, able, or reasonably available to make a health care\n\ndecision for me, I designate as my first alternate agent:\n\n___________________________________________________________________\n\n(name of individual you choose as first alternate agent)\n\nphone) (work phone)\n\nOPTIONAL: If I revoke my agent’s authority or if my agent is\n\nnot willing, able, or reasonably available to make a health care\n\ndecision for me, I designate as my first alternate agent:\n\n___________________________________________________________________\n\n(name of individual you choose as first alternate agent)\n\n___________________________________________________________________\n\n(address) (city) (state) (zip code)\n\n___________________________________________________________________\n\n(home phone) (work phone)\n\nOPTIONAL: If I revoke the authority of my agent and first\n\nalternate agent or if neither is willing, able, or reasonably\n\navailable to make a health care decision for me, I designate as my\n\nsecond alternate agent:\n\n___________________________________________________________________\n\n(name of individual you choose as second alternate agent)\n\n___________________________________________________________________\n\n(address) (city) (state) (zip code)\n\n___________________________________________________________________\n\n(home phone) (work phone)\n\n2. AGENT’S AUTHORITY: My agent is authorized to make all\n\nhealth care decisions (not to include the withholding or withdrawal\n\nof life-sustaining treatment, nutrition, or hydration, other than\n\nsigning a do-not-resuscitate consent) for me that I could make if I\n\nwere able, except as I state here:\n\n___________________________________________________________________\n\n___________________________________________________________________\n\n___________________________________________________________________\n\n(Add additional sheets if needed.)\n\n3. WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s\n\nauthority becomes effective when my attending physician determines\n\nthat I am unable to make my own health care decisions unless I mark\n\nthe following box. If I mark this box [ ], my agent’s authority\n\nto make health care decisions for me takes effect immediately.\n\n_____________\n\n(Initials)\n\n4. AGENT’S OBLIGATION: My agent shall make health care\n\ndecisions for me in accordance with this power of attorney for\n\nhealth care and my other wishes to the extent known to my agent. To\n\nthe extent my wishes are unknown, my agent shall make health care\n\ndecisions for me in accordance with what my agent determines to be\n\nin my best interest. In determining my best interest, my agent\n\nshall consider the decisions I would have made myself to the extent\n\nknown to my agent.\n\n_____________\n\n(Initials)\n\n5. RELIEF FROM PAIN: Except as I state in the following space,\n\nI direct that treatment for alleviation of pain or discomfort be\n\nprovided at all times, even if it hastens my death:\n\n________________________________________________________________\n\n________________________________________________________________\n\n6. OTHER WISHES: (If you do not agree with any of the optional\n\nchoices above and wish to write your own, or if you wish to add to\n\nthe instructions you have given above, you may do so here.) I\n\ndirect that:\n\n___________________________________________________________________\n\n___________________________________________________________________\n\n(Add additional sheets if needed.)\n\n7. EFFECT OF COPY: A copy of this form has the same effect as\n\nthe original.\n\n8. SIGNATURES: Sign and date the form here:\n\n_______________________________ ______________________________\n\n(date) (sign your name)\n\n_______________________________ ______________________________\n\n(address) (print your name)\n\n_______________________________\n\n(city) (state)\n\nState of Oklahoma\n\nCounty of ________\n\nSubscribed and sworn to before me this ___ day of ______, 20__.\n\n__________________________________\n\nNotary Public\n\nOR\n\nSIGNATURES OF WITNESSES:\n\nFirst witness Second witness\n\n______________________________ _______________________________\n\n(print name) (print name)\n________________\n\n(address) (print your name)\n\n_______________________________\n\n(city) (state)\n\nState of Oklahoma\n\nCounty of ________\n\nSubscribed and sworn to before me this ___ day of ______, 20__.\n\n__________________________________\n\nNotary Public\n\nOR\n\nSIGNATURES OF WITNESSES:\n\nFirst witness Second witness\n\n______________________________ _______________________________\n\n(print name) (print name)\n\n______________________________ _______________________________\n\n(address) (address)\n\n______________________________ ______________________________\n\n(city) (state) (city) (state)\n\n______________________________ ______________________________\n\n(signature of witness) (signature of witness)\n\n______________________________ ______________________________\n\n(date) (date)","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"dc7914403ce76dbe490ba6f301f476d478a200cc8ea5db32428c5e14e1367b15","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-3111.4","next":"us-ok/okla.-stat.-tit.-63-63-3111.6"},"notice":"GroundRules: Original legal text. Not legal advice."}