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) 522-3069, or your local legal
aid or legal services office. This document authorizes your agent to make medical and other health-care
decisions for you. You may revoke this power of attorney if you later wish to do so.
(insert name and address)
(insert name and address of the person appointed)
as my agent (attorney-in-fact) 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
To grant one or more, but fewer than all, of the following powers, initial the line in front of each power you
To withhold a power, do not initial the line in front of it. You may, but need not, cross out each power with
1. If I am unable to decide or speak for myself, my agent has the power to:
a. Make health and medical care decisions for me, including serving as my representative
under the Oklahoma Do-Not-Resuscitate Act, but excluding signing an advance
directive, making decisions reserved to a health care proxy under an advance directive,
or other life-sustaining 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
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: