STATEMENT OF DESIRES, 5
SPECIAL PROVISIONS OR LIMITATIONS
In exercising authority under this document, my health care agent shall act 7
consistently with my following stated desires, if any, and is subject to any special 8
provisions or limitations that I specify. The following are specific desires, provisions 9
or limitations that I wish to state (add more items if needed):
INSPECTION AND DISCLOSURE OF 14
INFORMATION RELATING TO MY PHYSICAL 15
OR MENTAL HEALTH
Subject to any limitations in this document, my health care agent has the 17
authority to do all of the following:
(a) Request, review and receive any information, oral or written, regarding my 19
physical or mental health, including medical and hospital records.
(b) Execute on my behalf any documents that may be required in order to obtain 21
(c) Consent to the disclosure of this information.
(The principal and the witnesses all must sign the document at the same time.)
SIGNATURE OF PRINCIPAL
(person creating the power of attorney for health care)
(The signing of this document by the principal revokes all previous powers of 3
attorney for health care documents.)
STATEMENT OF WITNESSES
I know the principal personally and I believe him or her to be of sound mind and 6
at least 18 years of age. I believe that his or her execution of this power of attorney 7
for health care is voluntary. I am at least 18 years of age, am not related to the 8
principal by blood, marriage, or adoption, am not the domestic partner under ch. 770 9
of the principal, and am not directly financially responsible for the principal's health 10
care. I am not a health care provider who is serving the principal at this time, an 11
employee of the health care provider, other than a chaplain or a social worker, or an 12
employee, other than a chaplain or a social worker, of an inpatient health care facility 13
in which the declarant is a patient. I am not the principal's health care agent. To 14
the best of my knowledge, I am not entitled to and do not have a claim on the 15
Witness No. 1:
(print) Name.... Date....
Witness No. 2:
(print) Name.... Date....
STATEMENT OF HEALTH CARE AGENT AND 25
ALTERNATE HEALTH CARE AGENT
I understand that.... (name of principal) has designated me to be his or her 2
health care agent or alternate health care agent if he or she is ever found to have 3
incapacity and unable to make health care decisions himself or herself. .... (name of 4
principal) has discussed his or her desires regarding health care decisions with me.
Failure to execute a power of attorney for health care document under chapter 10
155 of the Wisconsin Statutes creates no presumption about the intent of any 11
individual with regard to his or her health care decisions.
This power of attorney for health care is executed as provided in chapter 155 13
of the Wisconsin Statutes.
ANATOMICAL GIFTS (optional)
Upon my death:
.... I wish to donate only the following organs or parts: .... (specify the organs or 17
.... I wish to donate any needed organ or part.
.... I wish to donate my body for anatomical study if needed.
.... I refuse to make an anatomical gift. (If this revokes a prior commitment that 21
I have made to make an anatomical gift to a designated donee, I will attempt to notify 22
the donee to which or to whom I agreed to donate.)
Failing to check any of the lines immediately above creates no presumption 24
about my desire to make or refuse to make an anatomical gift.
SB377, s. 54
632.88 (1) (a) of the statutes is amended to read:
(a) Incapable of self-sustaining employment because of mental
3retardation intellectual disability
or physical handicap; and