Oklahoma Durable Power Of Attorney (With Health Care Powers Only) Page 2
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2d. My thoughts about how my medical condition might affect my family:
_______________________
_________________________________________________________________________________________
_________________________________________________________________________________________
e. My thoughts about living and receiving health care at home versus in a nursing home or other
institution:
________________________________________________________________________________
_________________________________________________________________________________________
Special Instructions: On the following lines you may give special instructions limiting or extending the
powers granted to your agent.
________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(Attach additional pages if needed.)
Please initial one statement below regarding the effective date of this power of attorney.
III. When Power Becomes Effective
Initial
This power of attorney is effective immediately and shall continue until it is revoked.
This power of attorney shall be effective when my attending physician determines that I am no longer
____
able to manage my person. This determination shall be provided in writing and attached to this form.
____
I agree that any third party who receives a copy of this document may act under it. Revocation of the power of
attorney is not effective as to a third party until the third party learns of the revocation. I agree to indemnify
the third party for any claims that arise against the third party because of reliance on this power of attorney.
Signed:
(Principal’s signature)
__________________________________________________________________________
City, County, and State of Residence
The principal is personally known to me and I believe the principal to be of sound mind. I am eighteen (18)
________________________________________________________________________________
years of age or older. I am not related to the principal by blood or marriage, or related to the attorneyinfact
by blood or marriage. The principal has declared to me that this instrument is his power of attorney granting to
the named attorneyinfact the power and authority specified herein, and that he has willingly made and exe
cuted it as his free and voluntary act for the purposes herein expressed.
Witness:
_____________________________________________
_______________________________
Witness:
__________________________
STATE OF OKLAHOMA
_____________________________________________
_____
SS.
)
COUNTY OF
)
_____________________
)
Before me, the undersigned authority, on this
_____
day of
_____________,
20
____,
personally appeared
_____________________________________
(principal),
__________________________________
(witness),
and
__________________________________
(witness), whose names are subscribed to the foregoing instru
ment in their respective capacities, and all of said persons being by me duly sworn, the principal declared to
me and to the said witnesses in my presence that the instrument is his or her power of attorney, and that the
principal has willingly and voluntarily made and executed it as the free act and deed of the principal for the
purposes therein expressed, and the witnesses declared to me that they were each eighteen (18) years of age or
over, and that neither of them is related to the principal by blood or marriage, or related to the attorneyinfact
by blood or marriage.
___________________________________
Notary Public
My Commission Expires:
_____________________
By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsi
bilities of an agent.
OKDHS Pub. No. 9963
Revised 1/2002
This publication is authorized by the Human Services Commission in accordance with state and federal regulations and printed by
the Oklahoma Department of Human Services at a cost of $1086.40 for 20,000 copies. Copies have been deposited with the
Publications Clearinghouse of the Oklahoma Department of Libraries. DHS offices may request copies on ADM9 electronic supply
orders. Members of the public may obtain copies by calling 18772834113 (toll free).
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