AB216,11,2 15156.15 Written request for medication; form. The department shall
16prepare and provide copies of a request for medication authorization form and
17accompanying information for distribution in quantities to health care providers,
18hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar
19associations and individually to private persons. The department shall include, in
20information accompanying the copy of the request for medication authorization
21form, at least the statutory definitions of terms used in the request for medication
22authorization form, statutory restrictions on who may be witnesses to a valid request
23for medication under s. 156.07, and a statement explaining that valid witnesses
24acting in good faith are statutorily immune from civil or criminal liability. The

1request for medication authorization form distributed by the department shall be in
2the following form:
AB216,11,76 I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
7a resident of Wisconsin.
AB216,11,108 I am suffering from .... (insert description of terminal disease), which my
9attending physician has determined is a terminal disease and which has been
10medically confirmed by a consulting physician.
AB216,11,1311 I have been fully informed of my diagnosis, prognosis, the nature of medication
12to be prescribed and potential associated risks, the expected result, and the feasible
13alternatives, including comfort care, hospice care, and pain control.
AB216,11,1514 I request that my attending physician prescribe medication that will end my life
15in a humane and dignified manner.
AB216,11,1817 .... I have informed my family members of my decision and taken their opinions
18into consideration.
AB216,11,1919 .... I have decided not to inform my family of my decision.
AB216,11,2020 .... I have no family to inform of my decision.
AB216,11,2121 I understand that I have the right to revoke this request at any time.
AB216,11,2322 I understand the full import of this request and I expect to die when I take the
23medication to be prescribed.
AB216,11,2524 I make this request voluntarily and without reservation, and I accept full moral
25responsibility for my actions.
1Signed: ....
AB216,12,22 Dated: ....
AB216,12,3 3Statement and signatures
AB216,12,4 4of witnesses
AB216,12,145 I know the requester personally or I have received proof of his or her identity
6and I believe him or her to be of sound mind and at least 18 years of age. I believe
7that the requester makes this request voluntarily. I am at least 18 years of age, am
8not related to the requester by blood, marriage, or adoption, and am not directly
9financially responsible for the requester's health care. I am not a health care
10provider who is serving the requester at this time; an employee of the health care
11provider, other than a chaplain or a social worker; or an employee, other than a
12chaplain or a social worker, of a health care facility in which the requester is a
13patient. To the best of my knowledge, I am not entitled to and do not have a claim
14on the requester's estate.
AB216,12,1515 Witness No. 1:
AB216,12,1616 (print) Name: ....
AB216,12,1717 Address: ....
AB216,12,1818 Signature: ....
AB216,12,1919 Witness No. 2:
AB216,12,2020 (print) Name: ....
AB216,12,2121 Address: ....
AB216,12,2222 Signature: ....
AB216,12,2323 Witness No. 3:
AB216,12,2424 (print) Name: ....
AB216,12,2525 Address: ....
1Signature: ....
AB216,13,52 If the requester is a resident of a nursing home or community-based residential
3facility, at least one of the above witnesses must be a residents' advocate designated
4by the board on aging and long-term care. A residents' advocate who is a witness
5should print “residents' advocate" after the printing of his or her name above.
AB216,13,7 6156.17 Revocation of request for medication. (1) A requester may revoke
7his or her request for medication at any time by doing any of the following:
AB216,13,108 (a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
9the written request for medication or directing another in the presence of the
10requester to destroy, in the same manner, the request for medication.
AB216,13,1211 (b) Executing a statement, in writing, that is signed and dated by the requester,
12expressing the requester's intent to revoke the request for medication.
AB216,13,1413 (c) Orally expressing the requester's intent to revoke the request for
14medication, in the presence of 2 witnesses or the attending physician.
AB216,13,18 15(2) A health care provider shall, upon notification of revocation of the
16requester's request for medication, record in the requester's medical record the time,
17date, and place of the revocation and the time, date, and place, if different, of the
18notification to the health care provider of the revocation.
AB216,13,25 19156.19 Designation of residents' advocates. The board on aging and
20long-term care shall designate staff of the long-term care ombudsman program as
21residents' advocates. A person so designated shall serve as a witness to a request for
22medication of a requester who is a resident of a nursing home or community-based
23residential facility, as required under s. 156.07 (2) (b), and shall speak on behalf of
24the requester to ensure that his or her needs or wants are communicated to and
25addressed by his or her attending physician.
1156.21 Duties and immunities. (1) No health care facility or health care
2provider may be charged with a crime, held civilly liable, or charged with
3unprofessional conduct for any of the following:
AB216,14,84 (a) Failing to fulfill a request for medication, except that failure of an attending
5physician to fulfill a request for medication constitutes unprofessional conduct if the
6attending physician refuses or fails to make a good faith attempt to transfer the
7requester's care and treatment to another physician who will act as attending
8physician under this chapter and fulfill the request for medication.
AB216,14,109 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
10medication that is in compliance with this chapter.
AB216,14,1311 (c) Acting contrary to or failing to act on a revocation of a request for medication,
12unless the health care facility or health care provider has actual knowledge of the
AB216,14,18 14(2) In the absence of actual notice to the contrary, a health care facility or a
15health care provider, other than a physician acting as the requester's attending
16physician under this chapter, may presume that a requester was authorized to make
17his or her request for medication under the requirements of this chapter and that the
18request for medication is valid.
AB216,14,21 19(3) (a) No person who acts in good faith as a witness to a request for medication
20under this chapter may be held civilly or criminally liable for a death that results
21from taking medication under a fulfilled request for medication under this chapter.
AB216,14,2322 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
23of s. 156.07 (2) (a).
AB216,15,2 24156.23 General provisions. (1) (a) The making of a request for medication
25under this chapter does not, for any purpose, constitute attempted suicide. Taking

1medication under a fulfilled request for medication under this chapter does not, for
2any purpose, constitute suicide.
AB216,15,53 (b) Paragraph (a) does not prohibit an insurer from making a determination
4that a requester has attempted suicide or committed suicide if the requester has so
5acted, apart from a request for medication.
AB216,15,8 6(2) The making of a request for medication under this chapter does not revoke
7or otherwise modify a power of attorney for health care or declaration to physicians
8that the requester may have executed.
AB216,15,12 9(3) No individual may be required to make a request for medication as a
10condition for receipt of health care or admission to a health care facility. The making
11of a request for medication is not a bar to the receipt of health care or the admission
12to a health care facility.
AB216,15,15 13(4) A written request for medication that has not been revoked and that is in
14its original form or is a legible photocopy or electronic facsimile copy is presumed to
15be valid.
AB216,15,19 16(5) Nothing in this chapter may be construed to condone, authorize, approve,
17or permit any affirmative or deliberate act to end life other than through taking
18medication that is prescribed under a request for medication as provided in this
AB216,15,23 20156.25 Record review. The department shall annually examine a sampling
21of patient health care records of requesters for whom medication was prescribed in
22fulfillment of a request for medication and about whom the department has received
23information under s. 156.09 (8) (g).
AB216,16,2 24156.27 Penalties. (1) Any person who willfully conceals, cancels, defaces,
25obliterates, or damages the request for medication of another without the requester's

1consent may be fined not more than $500 or imprisoned for not more than 30 days,
2or both.
AB216,16,7 3(2) Any person who, with the intent to cause a requester to take medication that
4is prescribed under a request for medication contrary to the wishes of the requester,
5illegally falsifies or forges the request for medication of another or conceals a
6revocation under s. 156.17 shall be fined not more than $10,000 or imprisoned for not
7more than 10 years, or both.
AB216,16,12 8(3) Any responsible person who, with the intent to cause a requester to take
9medication that is prescribed under a request for medication contrary to the wishes
10of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
11be fined not more than $10,000 or, except for a health care facility, imprisoned for not
12more than 10 years, or both.
AB216,4 13Section 4. 979.01 (1) (intro.) of the statutes is amended to read:
AB216,16,2014 979.01 (1) (intro.) All Except as provided in sub. (1j), all physicians, authorities
15of hospitals, sanatoriums, public and private institutions, convalescent homes,
16authorities of any institution of a like nature, and other persons having knowledge
17of the death of any person who has died under any of the following circumstances,
18shall immediately report the death to the sheriff, police chief, or and medical
19examiner or coroner of the county and to the police chief of any community where the
20death took place:
AB216,5 21Section 5. 979.01 (1g) of the statutes is amended to read:
AB216,17,222 979.01 (1g) A sheriff or police chief shall, immediately upon notification under
23sub. (1) or s. 948.23 (1) (b) of a death, notify the coroner or the medical examiner, and
24the coroner or medical examiner of the county where death took place
, if the crime,

1injury, or event occurred in another county, shall immediately report the death to the
2coroner or medical examiner of that county.
AB216,6 3Section 6. 979.01 (1j) of the statutes is created to read:
AB216,17,64 979.01 (1j) Subsection (1) does not apply to a death that results from taking
5medication under a fulfilled request for medication that meets the requirements of
6ch. 156.
AB216,7 7Section 7. 979.01 (1r) of the statutes is repealed.
AB216,17,88 (End)