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Oklahoma ___________________________________________ -4- _________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ ___ signed in my presence. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ __________________, 20 _____. -3- ________________________________________ (Signature) ___________________________________________________________ City, County and State of Residence This Health Care Proxy wase Proxies are revoked. f. I understand the full importance of this Health Care Proxy and I am emotionally and mentally competent to make this Health Care Proxy. Signed this ___________ day of ________ d. I understand that I may revoke this Health Care Proxy at any time. e. I understand and agree that if I have any prior Health Care Proxies, and if I sign this Health Care Proxy, my prior Health Carnt including, but not limited to, the administration of any life-sustaining procedures, and I accept the consequences of such refusal. c. This Health Care Proxy shall be in effect until it is revoked. life-sustaining procedures, it is my intention that this advance directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatmes is known to my attending physician, any directives give by me shall have no force or effect during the course of my pregnancy. b. In the absence of my ability to give directions regarding the use of________________________________________________________________ _______________________ (signature) IV. General Provisions a. I understand that if I have been diagnosed as pregnant and that diagnosie appointed a health care proxy, and if there is a conflict between my health care proxy's decision and my living will, my living will shall take precedence unless I indicate otherwise. ______________yes/cornea/lens, [___] glands, [___] other _____________ ______________ _______________________ (signature) III. Conflicting Provision I understand that if I have completed both a living will and havody organs or parts: [___] lungs, [___] liver, [___] pancreas, [___] heart, [___] kidneys, [___] brain, [___] skin, [___] bones/marrow, [___] bloods/fluids, [___] tissue, -2- [___] arteries, [___] eof circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. I specifically donate: [___] My entire body; or [___] The following bof transplantation, therapy, advancement of medical or dental science or research or education pursuant to the provisions of the Uniform Anatomical Gift Act. Death means either irreversible cessation ________________________ _______________________ (signature) II. Anatomical Gifts I direct that at the time of my death my entire body or designated body organs or body parts be donated for purposes y) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________g the withholding and withdrawal of artificially administered nutrition and hydration. _______________________ (signature) (3) I authorize my health care proxy to (add other medical directives, if and that if I do not sign this paragraph, artificially administered nutrition (food) and hydration (water) will be administered to me. I further understand that if I sign this paragraph, I am authorizin are absent. _______________________ (signature) (2) I understand that the subject of the artificial administration of nutrition and hydration (food and water) is of particular importance. I understanawn if such treatment will only serve to maintain me in an irreversible condition, as determined by my attending physician and another physician, in which thought and awareness of self and environment _______________________ (signature) c. If I am persistently unconscious (sign if applicable): -1- (1) I authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrcare proxy to (add other medical directives, if any) _________________________________________________________________________ _________________________________________________________________________tand that if I sign this paragraph, I am authorizing the withholding or withdrawal of artificially administered nutrition and hydration. _______________________ (signature) (3) I authorize my health and water) is of particular importance. I understand that if I do not sign this paragraph, artificially administered nutrition (food) or hydration (water) will be administered to me. I further unders-sustaining treatment will cause my death within six (6) months. _______________________ (signature) (2) I understand that the subject of the artificial administration of nutrition and hydration (foodtment would only prolong my process of dying and if my attending physician and another physician determine that I have an incurable and irreversible condition that even with the administration of lifee in the following sections. b. If I have a terminal condition (sign if applicable): (1) I authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrawn if such trear medical treatment decisions I could make if I were able, except that decisions regarding lifesustaining treatment can be made by my health care proxy or alternate health care proxy only as I indicatnable or unwilling to serve, I appoint ___________________________________________________ as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatevehe Terminally Ill or Persistently Unconscious Act to follow the instructions of __________________________________________________, whom I appoint as my health care proxy. If my health care proxy is uther physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers pursuant to the Oklahoma Rights of tr, willfully and voluntarily make known my desires and my wish to appoint a health care proxy. I thus do hereby declare: I. My Appointment of My Health Care Proxy a. If my attending physician and ano Disclaimers and Terms of Use found at findlegalforms.com -4- Health Care Proxy I, _______________________________________________________, being of sound mind and eighteen (18) years of age or oldement is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a docuand are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consultings is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended cisional capacity of the person. Such designation shall be specified and included as part of the advanced directive executed pursuant to the provisions of this section. [_] These forms are provided "ad on established religious beliefs or tenets may designate an individual other than the designated health care proxy, in lieu of an attending physician and other physician, to determine the lack of deining procedures if so indicated in the patient's advance directive. E. A person executing an advanced directive appointing a health care proxy who may not have an attending physician for reasons basehe patient's health care proxy, in consultation with the attending physician, shall have the authority to make treatment decisions for the patient including the withholding or withdrawal of life-sustaance directive shall make it a part of the Declarant's medical record and, if unwilling to comply with the advance directive, promptly so advise the Declarant. D. In the case of a qualified patient, tat law. B. An advance directive shall be in substantially the following form: (Form included below) C. A physician or other health care provider who is furnished the original or a photocopy of the adv life-sustaining treatment. The advance directive shall be signed by the Declarant and witnessed by two individuals who are eighteen (18) years of age or older who are not legatees, devisees or heirs - Advance Directive Form and Procedures. A. An individual of sound mind and eighteen (18) years of age or older may execute at any time an advance directive governing the withholding or withdrawal ofvider by the Declarant or a witness to the revocation. B. The attending physician or other health care provider shall make the revocation a part of the Declarant's medical record. -3- Section 3101.4ime and in any manner by the Declarant, without regard to the Declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health care prohe Declarant and shall become operative pursuant to subsection A of this section. Section 3101.6 - Revocation of Advance Directive. A. An advance directive may be revoked in whole or in part at any t of Section 9 of this act. B. In the event more than one valid advance directive has been executed and not revoked, the last advance directive so executed shall be construed to be the last wishes of tfesustaining treatment. When the advance directive becomes operative, the attending physician and other health care providers shall act in accordance with its provisions or comply wit h the provisionsmes Operative. A. An advance directive becomes operative when: 1. It is communicated to the attending physician; and 2. The Declarant is no longer able to make decisions regarding administration of liadministration of life-sustaining treatment, will, in the opinion of the attending physician and another physician, result in death within six (6) months. Section 3101.5 - When Advance Directive Becoitory, or possession of the United States, the District of Columbia, or the Commonwealth of Puerto Rico; and 12. "Terminal condition" means an incurable and irreversible condition that, even with the has been determined to be in a terminal condition or in a persistently unconscious state by the attending physician and another physician who have examined the patient; 11. "State" means a state, terr "Physician" means an individual licensed to practice medicine in this state; 10. "Qualified patient" means a patient eighteen (18) years of age or older who has executed an advance directive and who n" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, government, governmental subdivision or agency, or any other legal or commercial entity; 9.stently unconscious" means an irreversible condition, as determined by the attending physician and another physician, in which thought and awareness of self and environment are absent; -2- 8. "Persoing treatment" shall not include the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain nor the normal consumption of food and water; 7. "Persidration, that, when administered to a qualified patient, will serve only to prolong the process of dying or to maintain the patient in a condition of persistent unconsciousness. The term "life-sustainng but not limited to the artificial administration of nutrition and hydration if the Declarant has specifically authorized the withholding and withdrawal of artificially administered nutrition and hyphysician, is persistently unconscious, incompetent, or otherwise mentally or physically incapable of communication; 6. "Life-sustaining treatment" means any medical procedure or intervention, includiact to make health care decisions including but not limited to the withholding or withdrawal of life-sustaining treatment if a qualified patient, in the opinion of the attending physician and another nister health care in the ordinary course of business or practice of a profession; 5. "Health care proxy" is an individual eighteen (18) years old or older appointed by the Declarant as attorney- in-firective according to the procedure provided for in Section 4 of this act; 4. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to admitment of a proxy; 2. "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient; 3. "Declarant" means any individual who has issued an advance dcare" means any writing executed in accordance with the requirements of Section 4 of this act and may include a living will, the appointment of a health care proxy, or both such living will and appoinmercy killing, assisted suicide, or euthanasia. Section 3101.3 - Terms Defined. As used in the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act: 1. "Advance directive for health th on the instructions of the individual and the decisions of an authorized proxy. C. The Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act does not condone, authorize, or approve effective, the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act also -1- includes necessary and appropriate protection for proxies and health care providers who rely in good faidividual in advance of incapacity and the delegation of decision- making powers to a health care proxy. B. To be sure that the individual's health care instructions and proxy decision- making will be ensure that the individual's advance directive for health care will continue to be honored during incapacity without court involvement; and 5. Encourage and support health care instructions by the inrt is to settle disputes and to act as the proxy decision- maker of last resort when no other proxy is authorized by the individual or is otherwise authorized by law; 4. Restate and clarify the law toes, the proxy's decisions should be based on the proxy's reasonable judgment about the individual's values and what the individual's wishes would be based upon those values. The proper role of the couns, personal views, or best interests of the individual. If evidence of the individual's wishes is sufficient, those wishes should control; if there is not sufficient evidence of the individual's wish highly sensitive, personal issues that do not belong in court, even if the individual is incapacitated, so long as a proxy decision- maker can make the necessary decisions based on the known intentiond overrides any obligation the physician and other health care providers may have to render care or to preserve life and health; 3. Recognize that decisions concerning one's medical treatment involvect that it be withdrawn, even if death ensues; 2. Recognize that the right of individuals to control some aspects of their own medical treatment is protected by the Constitution of the United States anscious Act is to: 1. Recognize the right of individuals to control some aspects of their own medical care and treatment, including but not limited to the right to decline medical treatment or to dire from the Oklahoma Statutes relating to the Oklahoma Power of Attorney for Health Care Form. Section 3101.2 - Purpose. A. The purpose of the Oklahoma Rights of the Terminally Ill or Persistently Uncorney for Health Care Form. This Oklahoma Power of Attorney for Health Care is based in part on Title 63; Chapter 60; Section 3101.2 et. Seq. of the Oklahoma Statutes. The following are useful excerptsInformation and Instructions Oklahoma Power of Attorney for Health Care This package contains (1) Information and Instruction for Oklahoma Power of Attorney for Health Care; (2) Oklahoma Power of Atto Oklahoma