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 patient's declaration 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.
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 patient) ________________________________________, 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 _____________, 19__
___________________, M.D., D.O., Ph.D., Other
___________________, M.D., D.O., Ph.D., Other
Subscribed and sworn to before me this _______________________ day of ________________, 19__
__________________________________________
Notary Public
REPORT OF SYMPTOMS AND HISTORY OF
CASE BY EXAMINERS 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
___________________, 19__
_____________, M.D., D.O., Ph.D., Other
_______________________________________
Address
_____________, M.D., D.O., Ph.D., Other
_______________________________________
Address
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 _____________________:
Added by Laws 1995, HB 1353, c. 251, § 10, eff. November 1, 1995.