Medical Power of Attorney Form for Oklahoma

DOCUMENT CONTROL AND SPECIFICATIONS

Document Title: Oklahoma Advance Directive for Health Care and Durable Power of Attorney for Healthcare Decisions Document ID: OK-MPOA-2024-V1.0 Effective Date: [Effective Date] Version: 1.0 (Statutory Compliance: 63 O.S. § 3101.4) Governing Jurisdiction: State of Oklahoma

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STATUTORY & LEGAL COMPLIANCE NOTICE

NOTICE TO PERSON EXECUTING THIS DOCUMENT: This is an important legal document. It creates a durable power of attorney for health care. Before executing this document, you should know these important facts: This document gives the person you designate as your agent (the Health Care Proxy) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known. This document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. This document is intended to be compliant with the Oklahoma Advance Directive Act (63 O.S. § 3101.1 et seq.).

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I. PARTIES AND RECITALS

This Durable Power of Attorney for Healthcare and Advance Directive is entered into by:

PRINCIPAL: [Principal Full Legal Name], residing at [Principal Address], (hereinafter referred to as the "Principal").

HEALTH CARE AGENT: [Agent Full Legal Name], residing at [Agent Address], (hereinafter referred to as the "Proxy").

RECITALS: WHEREAS, the Principal, being of sound mind and over the age of eighteen (18) years, willfully and voluntarily intends to provide instructions for health care and to designate a Proxy to make health care decisions in the event the Principal is unable to make such decisions independently;

NOW, THEREFORE, in consideration of the mutual covenants contained herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Principal declares as follows:

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II. EXHAUSTIVE OPERATIVE CLAUSES

1. SCOPE OF ENGAGEMENT & DESIGNATION

The Principal hereby appoints [Agent Full Legal Name] as the Principal’s Health Care Proxy. This appointment shall become effective only at such time as the Principal’s attending physician and a second physician determine that the Principal is no longer able to make decisions regarding health care. This authority is limited to health care decisions and shall not include the authority to make financial or real estate decisions on behalf of the Principal.

2. REIMBURSEMENT OF EXPENSES & COMPENSATION

The Proxy shall serve without compensation for services rendered. However, the Proxy is entitled to immediate reimbursement from the Principal’s estate or existing liquid assets for all reasonable and necessary out-of-pocket expenses incurred in the performance of their duties under this agreement, including but not limited to travel, lodging, and professional consultation fees required to make informed medical decisions.

3. TERM & TERMINATION

This document shall remain in full force and effect until the death of the Principal, unless sooner revoked by the Principal. Revocation may be performed at any time and in any manner (oral, written, or by destruction of the document) by the Principal, regardless of the Principal’s mental or physical condition. Revocation is effective upon communication to the attending physician or the Proxy.

4. ACCESS TO PROTECTED HEALTH INFORMATION (HIPAA COMPLIANCE)

The Principal intends for the Proxy to be treated as the Principal’s "personal representative" for purposes of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The Proxy is hereby authorized to: (a) Request, receive, and review any information, oral or written, regarding the Principal’s physical or mental health, including medical and hospital records; (b) Execute on the Principal's behalf any releases or other documents that may be required in order to obtain this information; and (c) Consent to the disclosure of this information.

5. OWNERSHIP OF RECORDS & WORK PRODUCT

All medical records, diagnostic images, and health data obtained by the Proxy in the course of their duties remain the property of the respective medical providers; however, the Proxy shall have the absolute right to maintain copies of such records for the duration of their appointment to ensure continuity of care and informed decision-making.

6. REPRESENTATIONS AND WARRANTIES

The Principal represents and warrants that: (a) They are executing this document voluntarily and under no duress or undue influence; (b) They are of sound mind and possess the legal capacity to enter into this agreement; (c) All previous Health Care Powers of Attorney or Advance Directives are hereby revoked.

7. LIMITATION OF LIABILITY & INDEMNIFICATION

The Proxy shall not be liable to the Principal, the Principal’s heirs, or the Principal’s estate for any medical decision made in good faith and in accordance with the terms of this document. The Principal’s estate shall indemnify and hold the Proxy harmless from any and all liability, including attorney fees, arising out of the Proxy's good-faith performance of their duties, except in cases of gross negligence or willful misconduct.

8. SPECIFIC DIRECTIVES (LIVING WILL)

In the event the Principal has a terminal condition, is persistently unconscious, or has an end-stage condition as defined by Oklahoma law: (a) Life-Sustaining Treatment: The Principal directs that life-sustaining treatment (including but not limited to ventilators and dialysis) shall be: [Choose: (1) Provided, (2) Withheld/Withdrawn] as determined by the Proxy. (b) Artificially Administered Nutrition and Hydration: The Principal directs that food and water via medical tubes shall be: [Choose: (1) Provided, (2) Withheld/Withdrawn] as determined by the Proxy.

9. DISPUTE RESOLUTION

In the event of a dispute between the Proxy and any family member or medical provider regarding the interpretation of the Principal’s wishes, the parties shall first attempt mediation. If mediation fails, the dispute shall be resolved through binding arbitration in the county of the Principal's residence, in accordance with the rules of the American Arbitration Association.

10. GOVERNING LAW

This document is executed in the State of Oklahoma and shall be governed by, and construed in accordance with, the laws of Oklahoma, specifically the Oklahoma Advance Directive Act.

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III. EXECUTION & FORMAL SIGNATURE BLOCKS

IN WITNESS WHEREOF, the Principal has executed this document on the date first written above.

FOR THE PRINCIPAL:

Signature: _____________________________________ Printed Name: [Principal Full Legal Name] Address: [Principal Address] Date: [Date]

WITNESS ATTESTATION: I declare that the Principal is personally known to me, that I believe the Principal to be of sound mind, and that the Principal has signed this document in my presence. I am not related to the Principal by blood or marriage, nor am I entitled to any portion of the Principal's estate.

WITNESS 1: Signature: _____________________________________ Printed Name: __________________________________ Address: _______________________________________ Date: __________________________________________

WITNESS 2: Signature: _____________________________________ Printed Name: __________________________________ Address: _______________________________________ Date: __________________________________________

FOR THE PROXY (ACCEPTANCE OF APPOINTMENT):

Signature: _____________________________________ Printed Name: [Agent Full Legal Name] Title: Health Care Proxy / Agent Date: [Date]

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IV. NOTARY ACKNOWLEDGMENT

(Optional but highly recommended for institutional enforceability)

STATE OF OKLAHOMA ) COUNTY OF [County Name] )

Before me, the undersigned authority, on this day personally appeared [Principal Full Legal Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that they executed the same for the purposes and consideration therein expressed.

Given under my hand and seal of office this ____ day of ________, 20.

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NOTARY PUBLIC, State of Oklahoma My Commission Expires: ________________

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STEP-BY-STEP EXECUTION & FILING GUIDE

1. Preparation of the Document

• Bracketed Fields: Open this document in Microsoft Word or Google Docs. Use the "Find and Replace" function (Ctrl+H) to replace all [Bracketed Terms] with the specific legal names and addresses of the Principal and Proxy.
• Decision Selection: In Section II.8, ensure you clearly type or circle the desired choice regarding life-sustaining treatment.

2. Witness Selection

• Statutory Requirement: You must have two (2) witnesses present when you sign.
• Disqualification: Witnesses cannot be:
  • Under 18 years of age.
  • Related to you by blood or marriage.
  • Beneficiaries of your will or estate.
  • Financially responsible for your medical care.

3. Physical Execution

• Sign in Ink: Print the document and sign with a blue or black ink pen in the presence of the witnesses and a Notary Public.
• Digital Signature: If using DocuSign or Adobe Sign, ensure the platform provides a "Certificate of Completion" that captures the IP addresses and timestamps of all signatories, including witnesses. Note: Some hospitals may still prefer "wet" ink signatures for immediate recognition.

4. Distribution and Record Retention

• Primary Copy: Keep the original in a secure but accessible location (not a safe deposit box that requires a court order to open).
• Medical Providers: Provide a copy to your primary care physician and any hospital where you are receiving treatment. Ask that it be uploaded to your Electronic Health Record (EHR).
• Proxy: Ensure your Health Care Proxy has a digital and physical copy of this document.
• Registry: While Oklahoma does not have a mandatory state registry, you should keep a copy in a digital "Legacy" folder shared with your legal counsel.