SB334,3,619 IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL
20DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE
21HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE
22DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH
23CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR
24THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE
25PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN

1THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT
2DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE
3AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES
4WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS
5REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN
6MAKING THE DECISION.
SB334,3,197 THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT
8BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT
9REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU
10MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY
11FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY
12DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN
13YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY
14STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF
15YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE
16PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY.
17 IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR
18YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT
19IS INVALID.
SB334,4,2 20YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE
21AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT
22TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT
23REVOKES ANY PRIOR DOCUMENT OF GIFT THAT YOU MAY HAVE MADE.
24YOU MAKE REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE

1BY THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS
2PROVISION IN THIS DOCUMENT.
SB334,4,43 DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND
4IT.
SB334,4,65 IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS
6DOCUMENT ON FILE WITH YOUR PHYSICIAN.".
SB334, s. 2 7Section 2. 155.30 (3) of the statutes is amended to read:
SB334,4,208 155.30 (3) The department shall prepare and provide copies of a power of
9attorney for health care instrument and accompanying information for distribution
10in quantities to health care professionals, hospitals, nursing homes, multipurpose
11senior centers, county clerks and local bar associations and individually to private
12persons. The department shall include, in information accompanying the copy of the
13instrument, at least the statutory definitions of terms used in the instrument,
14statutory restrictions on who may be witnesses to a valid instrument, a statement
15explaining that valid witnesses acting in good faith are statutorily immune from civil
16or criminal liability and a statement explaining that an instrument may, but need
17not, be filed with the register in probate of the principal's county of residence. The
18department may charge a reasonable fee for the cost of preparation and distribution.
19The power of attorney for health care instrument distributed by the department
20shall include the notice specified in sub. (1) and shall be in the following form:
SB334,4,2121 POWER OF ATTORNEY
SB334,4,2222 FOR HEALTH CARE
SB334,4,2323 Document made this.... day of.... (month),.... (year).
SB334,4,2424 CREATION OF POWER OF
SB334,4,2525 ATTORNEY FOR HEALTH CARE
SB334,5,8
1I,.... (print name, address and date of birth), being of sound mind, intend by this
2document to create a power of attorney for health care. My executing this power of
3attorney for health care is voluntary. Despite the creation of this power of attorney
4for health care, I expect to be fully informed about and allowed to participate in any
5health care decision for me, to the extent that I am able. For the purposes of this
6document, "health care decision" means an informed decision to accept, maintain,
7discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
8or treat my physical or mental condition.
SB334,5,10 9In addition, I may, by this document, specify my wishes with respect to making
10an anatomical gift upon my death.
SB334,5,1111 DESIGNATION OF HEALTH CARE AGENT
SB334,6,212 If I am no longer able to make health care decisions for myself, due to my
13incapacity, I hereby designate.... (print name, address and telephone number) to be
14my health care agent for the purpose of making health care decisions on my behalf.
15If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
16address and telephone number) to be my alternate health care agent for the purpose
17of making health care decisions on my behalf. Neither my health care agent or nor
18my alternate health care agent whom I have designated is my health care provider,
19an employe of my health care provider, an employe of a health care facility in which
20I am a patient or a spouse of any of those persons, unless he or she is also my relative.
21For purposes of this document, "incapacity" exists if 2 physicians or a physician and
22a psychologist who have personally examined me sign a statement that specifically
23expresses their opinion that I have a condition that means that I am unable to receive
24and evaluate information effectively or to communicate decisions to such an extent

1that I lack the capacity to manage my health care decisions. A copy of that statement
2must be attached to this document.
SB334,6,33 GENERAL STATEMENT OF
SB334,6,44 AUTHORITY GRANTED
SB334,6,115 Unless I have specified otherwise in this document, if I ever have incapacity I
6instruct my health care provider to obtain the health care decision of my health care
7agent, if I need treatment, for all of my health care and treatment. I have discussed
8my desires thoroughly with my health care agent and believe that he or she
9understands my philosophy regarding the health care decisions I would make if I
10were able. I desire that my wishes be carried out through the authority given to my
11health care agent under this document.
SB334,6,2012 If I am unable, due to my incapacity, to make a health care decision, my health
13care agent is instructed to make the health care decision for me, but my health care
14agent should try to discuss with me any specific proposed health care if I am able to
15communicate in any manner, including by blinking my eyes. If this communication
16cannot be made, my health care agent shall base his or her decision on any health
17care choices that I have expressed prior to the time of the decision. If I have not
18expressed a health care choice about the health care in question and communication
19cannot be made, my health care agent shall base his or her health care decision on
20what he or she believes to be in my best interest.
SB334,6,2121 LIMITATIONS ON
SB334,6,2222 MENTAL HEALTH TREATMENT
SB334,7,223 My health care agent may not admit or commit me on an inpatient basis to an
24institution for mental diseases, an intermediate care facility for the mentally
25retarded, a state treatment facility or a treatment facility. My health care agent may

1not consent to experimental mental health research or psychosurgery,
2electroconvulsive treatment or drastic mental health treatment procedures for me.
SB334,7,33 ADMISSION TO NURSING HOMES OR
SB334,7,44 COMMUNITY-BASED RESIDENTIAL FACILITIES
SB334,7,65 My health care agent may admit me to a nursing home or community-based
6residential facility for short-term stays for recuperative care or respite care.
SB334,7,97 If I have checked "Yes" to the following, my health care agent may admit me for
8a purpose other than recuperative care or respite care, but if I have checked "No" to
9the following, my health care agent may not so admit me:
SB334,7,1010 1. A nursing home — Yes.... No....
SB334,7,1111 2. A community-based residential facility — Yes.... No....
SB334,7,1412 If I have not checked either "Yes" or "No" immediately above, my health care
13agent may only admit me only for short-term stays for recuperative care or respite
14care.
SB334,7,1515 PROVISION OF A FEEDING TUBE
SB334,7,2016 If I have checked "Yes" to the following, my health care agent may have a
17feeding tube withheld or withdrawn from me, unless my physician has advised that,
18in his or her professional judgment, this will cause me pain or will reduce my comfort.
19If I have checked "No" to the following, my health care agent may not have a feeding
20tube withheld or withdrawn from me.
SB334,7,2321 My health care agent may not have orally ingested nutrition or hydration
22withheld or withdrawn from me unless provision of the nutrition or hydration is
23medically contraindicated.
SB334,7,2424 Withhold or withdraw a feeding tube — Yes.... No....
SB334,8,2
1If I have not checked either "Yes" or "No" immediately above, my health care
2agent may not have a feeding tube withdrawn from me.
SB334,8,33 HEALTH CARE DECISIONS
SB334,8,44 FOR PREGNANT WOMEN
SB334,8,85 If I have checked "Yes" to the following, my health care agent may make health
6care decisions for me even if my agent knows I am pregnant. If I have checked "No"
7to the following, my health care agent may not make health care decisions for me if
8my health care agent knows I am pregnant.
SB334,8,99 Health care decision if I am pregnant — Yes.... No....
SB334,8,1210 If I have not checked either "Yes" or "No" immediately above, my health care
11agent may not make health care decisions for me if my health care agent knows I am
12pregnant.
SB334,8,1313 STATEMENT OF DESIRES, SPECIAL
SB334,8,1414 PROVISIONS OR LIMITATIONS
SB334,8,1815 In exercising authority under this document, my health care agent shall act
16consistently with my following stated desires, if any, and is subject to any special
17provisions or limitations that I specify. The following are specific desires, provisions
18or limitations that I wish to state (add more items if needed):
SB334,8,1919 1) -
SB334,8,2020 2) -
SB334,8,2121 3) -
SB334,8,2222 INSPECTION AND DISCLOSURE OF
SB334,8,2323 INFORMATION RELATING TO MY
SB334,8,2424 PHYSICAL OR MENTAL HEALTH
SB334,9,2
1Subject to any limitations in this document, my health care agent has the
2authority to do all of the following:
SB334,9,43 (a) Request, review and receive any information, verbal oral or written,
4regarding my physical or mental health, including medical and hospital records.
SB334,9,65 (b) Execute on my behalf any documents that may be required in order to obtain
6this information.
SB334,9,77 (c) Consent to the disclosure of this information.
SB334,9,88 (The principal and the witnesses all must sign the document at the same time.)
SB334,9,99 SIGNATURE OF PRINCIPAL
SB334,9,1010 (person creating the power
SB334,9,1111 of attorney for health care)
SB334,9,1212 Signature.... Date....
SB334,9,1413 (The signing of this document by the principal revokes all previous powers of
14attorney for health care documents.)
SB334,9,1515 STATEMENT OF WITNESSES
SB334,9,2516 I know the principal personally and I believe him or her to be of sound mind and
17at least 18 years of age. I believe that his or her execution of this power of attorney
18for health care is voluntary. I am at least 18 years of age, am not related to the
19principal by blood, marriage or adoption and am not directly financially responsible
20for the principal's health care. I am not a health care provider who is serving the
21principal at this time, an employe of the health care provider, other than a chaplain
22or a social worker, or an employe, other than a chaplain or a social worker, of an
23inpatient health care facility in which the declarant is a patient. I am not the
24principal's health care agent. To the best of my knowledge, I am not entitled to and
25do not have a claim on the principal's estate.
SB334,10,1
1Witness No. 1:
SB334,10,22 (print) Name.... Date....
SB334,10,33 Address....
SB334,10,44 Signature....
SB334,10,55 Witness No. 2:
SB334,10,66 (print) Name.... Date....
SB334,10,77 Address....
SB334,10,88 Signature....
SB334,10,99 STATEMENT OF HEALTH CARE AGENT
SB334,10,1010 AND ALTERNATE HEALTH CARE AGENT
SB334,10,1411 I understand that.... (name of principal) has designated me to be his or her
12health care agent or alternate health care agent if he or she is ever found to have
13incapacity and unable to make health care decisions himself or herself. .... (name
14of principal) has discussed his or her desires regarding health care decisions with me.
SB334,10,1515 Agent's signature....
SB334,10,1616 Address....
SB334,10,1717 Alternate's signature....
SB334,10,1818 Address....
SB334,10,2119 Failure to execute a power of attorney for health care document under chapter
20155 of the Wisconsin Statutes creates no presumption about the intent of any
21individual with regard to his or her health care decisions.
SB334,10,2322 This power of attorney for health care is executed as provided in chapter 155
23of the Wisconsin Statutes.
SB334,10,24 24ANATOMICAL GIFTS (OPTIONAL)
SB334,10,25 25Upon my death:
SB334,11,2
1.... I wish to donate only the following organs or parts: .... (specify the organs
2or parts).
SB334,11,3 3.... I wish to donate any needed organ or part.
SB334,11,4 4.... I wish to donate my body for anatomical study if needed.
SB334,11,5 5.... I refuse to make an anatomical gift.
SB334,11,7 6Failing to check any of the lines immediately above creates no presumption
7about my desire to make or refuse to make an anatomical gift.
SB334,11,8 8Signature.... Date....
SB334, s. 3 9Section 3. 157.06 (2) (f) 1m. of the statutes is created to read:
SB334,11,1110 157.06 (2) (f) 1m. Signing a new document of gift. Signing a new document of
11gift revokes any previously signed document of gift.
SB334, s. 4 12Section 4. 157.06 (2) (f) 6. of the statutes is created to read:
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