Okla. Stat. tit. 43A, § 11-110
C. The attending physician or psychologist is authorized to act in accordance with an operative advance directive for mental health treatment when the declarant has been determined to be incapable and mental health treatment is necessary. Except as otherwise provided by this act with regard to conflicting instructions in an advance directive for mental health treatment:
D. An attending physician or psychologist who is unable to comply with the terms of the declaration of the consumer shall make the necessary arrangements to transfer the patient and the appropriate medical records without delay to another physician or psychologist.
E. The following certification of the examination of a declarant determining whether the declarant is in need of mental health treatment and whether the declarant is or is not incapable may be utilized by examiners:
(Is) (Is not) incapable to participate in decisions about (her) (his) mental health treatment.
1. GENERAL
Complete name ________________________________________________
Place of residence ___________________________________________
Sex _______________ Color ________________
Age _______________
Date of Birth ________________________________________________
2. STATEMENT OF FACTS AND CIRCUMSTANCES
Our determination that the declarant (is) (is not) in need for mental health treatment is based on the following:________________________________________________________
__________________________________________________________________
Our determination that the declarant (is) (is not) incapable of participating in mental health treatment decisions is based on the following:________________________________________________________
__________________________________________________________________
3. NAME AND RELATIONSHIPS OF FAMILY MEMBERS/OTHERS TO BE NOTIFIED
Other data ___________________________________________________
Dated at _____________, Oklahoma, this __________ day of ___________________, 20 __
_____________, M.D., D.O., Ph.D., Other
_______________________________________
Address
_____________, M.D., D.O., Ph.D., Other
_______________________________________
Address
The facts and circumstances on which we base our opinions are stated in the following report of symptoms and history of case, which is hereby made a part hereof.
According to the advance directive for mental health treatment,
(name of consumer)_________________________________________, wishes to receive mental health treatment in accordance with the preferences and instructions stated in the advance directive for mental health treatment.
We are duly licensed to practice in the State of Oklahoma, are not related to _______________ by blood or marriage, and have no interest in her/his estate.
Witness our hands this ____________ day of _____________, 20__
___________________, M.D., D.O., Ph.D., Other ___________________, M.D., D.O., Ph.D., Other
Subscribed and sworn to before me this ______________________ day of ________________, 20 __
__________________________________________
Notary Public
REPORT OF SYMPTOMS AND HISTORY OF
CASE BY EXAMINERS
EXAMINER’S CERTIFICATION
We, the undersigned, have made an examination of _______________, and do hereby certify that we made a careful personal examination of the actual condition of the person and on such examination we find that _____________________:
Laws 1995, HB 1353, c. 251, § 10, eff. November 1, 1995; Amended by Laws 2005, HB 1845, c. 150, § 74, emerg. eff. May 9, 2005 (superseded document available).