1. A. Any relative related to a child within the third degree who has permanent care and custody of the child pursuant to Sections 21.2, 21.3 and 21.4 of Title 10 of the Oklahoma Statutes shall have the same rights to authorize medical care and dental care for the minor and to consent to school-related medical care on behalf of the minor that are given to legal guardians pursuant to Sections 21.5, 170.1 and 170.2 of Title 10 of the Oklahoma Statutes, or by the Oklahoma Guardianship and Conservatorship Act. A relative as specified by this subsection may complete a relative caregiver authorization affidavit.

2. B.

   1. 1. During the period of time after a child has been willfully left in the custody of a relative related to the child within the third degree, but prior to the time a child is deemed abandoned pursuant to Section 21.2 of Title 10 of the Oklahoma Statutes, the relative shall have the same rights to authorize medical care and dental care for the minor and to consent to school-related medical care on behalf of the minor that are given pursuant to subsection A of this section if:

      1. a. the relative completes the relative caregiver's authorization affidavit as required by this section,
      2. b. the child is residing full-time with the relative and the relative contributes the major degree of support for the child, and
      3. c. the parents have expressed a willful intent by words, actions or omissions not to return for the child, and the relative is unable to contact the parent, or the parent refuses to regain physical custody of the child after a written request to do so by the relative.
   2. 2. Until a child is deemed abandoned pursuant to Sections 21.2 through 21.4 of Title 10 of the Oklahoma Statutes, the decision of a relative to consent to or to refuse medical or dental care for a minor pursuant to this subsection shall be superseded by any contravening decision of the parent of the minor, provided the decision of the parent of the minor does not jeopardize the life, health, or safety of the minor.
   3. 3. The affidavit completed pursuant to this subsection shall not be valid for more than one (1) year after the date on which it is executed unless the relative has legal custody pursuant to subsection A of this section.

3. C.

   1. 1. A person who acts in good faith reliance on a relative caregiver’s authorization affidavit authorized by this section to provide medical or dental care, without actual knowledge of facts contrary to those stated on the affidavit, shall not be subject to criminal liability, civil liability to any person, or subject to professional disciplinary action if the applicable portions of the affidavit are completed.
   2. 2. A person who relies on the affidavit has no obligation to make any further inquiry or investigation.
   3. 3. Nothing in this section shall relieve any individual from liability for violations of other provisions of law.
   4. 4. If the minor stops residing with the relative, the relative shall notify any school, health care provider, or health care service plan that has been given a copy of the affidavit.

4. D. The relative caregiver's authorization affidavit shall be in substantially the following form:

   1. 1. Name of minor: ____________________________________________________.
   2. 2. Minor's birth date: __________________________________________________.
   3. 3. My name (adult giving authorization): __________________________________.

   4. 4. My home address: _________________________________________________ _________________________________________________

      _________________________________________________.

   5. 5. ( ) I am a grandparent, aunt, uncle, or other qualified relative of the minor (see end of this form for a definition of "qualified relative").
   6. 6. The child has been living in my home since _____________________________.

   7. 7. Check one or both (for example, if one parent was advised and the other cannot be located):

      ( ) The child has been left in my custody and I have advised the parent(s) or other person(s) having legal custody of the minor, in writing, of my intent to authorize medical care, and have received no objection.

      ( ) The child has been left in my custody and I am unable to contact or locate the parent(s) or other person(s) having legal custody of the minor at this time, to notify them of my intended authorization.

   8. 8. My date of birth: ___________________________________________________.

   9. 9. My Oklahoma driver license or identification card number: _________________

      ___________________________________________________________________
      Warning: Do not sign this form if any of the statements above are incorrect, or you will be committing a crime punishable by a fine, imprisonment, or both.

      I declare under penalty of perjury under the laws of the State of Oklahoma that the foregoing is true and correct.

      Dated: __________________ Signed: ____________________________________

      ______________________________________
      Notary Stamp

      Procedures:

   10. 1. The signature of the relative must be notarized.
   11. 2. This declaration does not affect the rights of the minor's parents or legal guardian regarding the care, custody, and control of the minor, and does not necessarily mean that the caregiver has legal custody of the minor.
   12. 3. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.

   13. 4. Unless the relative has legal custody of the child pursuant to Sections 21.2 through 21.4 of Title 10 of the Oklahoma Statutes, this affidavit is not valid for more than one (1) year after the date on which it is executed but may be reexecuted.

       Additional Information:

       TO CAREGIVERS:

   14. 1. "Qualified relative" for purposes of item 5, means a spouse of the qualified relative, parent, grandparent, great-grandparent, brother, sister, half-brother, half-sister, uncle, aunt, niece or nephew.
   15. 2. The law requires a caregiver, who is not a qualified relative of a child, to notify the Department of Human Services that a child in the caregiver’s care has been abandoned. If the caregiver wishes to continue to care for the child, the law further requires that the caregiver's home be approved as a foster home. A caregiver should direct any questions to the Department of Human Services.
   16. 3. If the child stops living with the caregiver, the caregiver is required to notify any school, health care provider or health care service plan to which an affidavit has been given that the child no longer resides with the caregiver.

   17. 4. If a caregiver does not have the information requested in item 9 (Oklahoma driver license or identification card), the caregiver must provide another form of identification, such as a social security number.

       TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

   18. 1. No person who acts in good faith reliance upon a caregiver’s properly completed authorization affidavit to provide medical or dental care, without actual knowledge of facts contrary to those stated on the affidavit, shall be subject to criminal liability, civil liability to any person, or subject to professional disciplinary action for relying upon the affidavit to provide medical or dental care.
   19. 2. This affidavit does not confer dependency for health care coverage purposes.

   Relative Caregiver's Authorization Affidavit

   Use of this affidavit is authorized by Section 21.6 of Title 10 of the Oklahoma Statutes.

   Instructions: Completion of items 1-5 and the signing of the affidavit are sufficient to authorize school-related medical care. Completion of items 6-9 is additionally required to authorize any other medical care. Print clearly.

   The minor named below lives full-time in my home and I am 18 years of age or older.

5. E. Any person who willfully makes a statement in the relative caregiver’s authorization affidavit which the person knows to be false shall, upon conviction, be guilty of a misdemeanor punishable by imprisonment in the county jail for not more than one (1) year or a fine of not more than Five Hundred Dollars ($500.00) or both such fine and imprisonment.

6. F. For purposes of this part:

   1. 1. "Person" includes an individual, corporation, partnership, association, the state, or any city, county, city and county, or other public entity or governmental subdivision or agency, or any other legal entity;
   2. 2. "Relative" means a spouse of the relative, parent, grandparent, great-grandparent, brother, sister, half-brother, half-sister, uncle, aunt, niece or nephew; and
   3. 3. "School-related medical care" means medical care that is required by state or local governmental authority as a condition for school enrollment, including immunizations, physical examinations and medical examinations conducted in schools for pupils.

Added by Laws 2001, HB 1670, c. 434, § 3, emerg. eff. June 8, 2001.