AB915,9,1818 2) -
AB915,9,1919 3) -
AB915,9,2020 INSPECTION AND DISCLOSURE OF INFORMATION
AB915,9,2121 RELATING TO MY PHYSICAL OR MENTAL HEALTH
AB915,9,2322 Subject to any limitations in this document, my health care agent has the
23authority to do all of the following:
AB915,9,2524 (a) Request, review and receive any information, oral or written, regarding my
25physical or mental health, including medical and hospital records.
AB915,10,2
1(b) Execute on my behalf any documents that may be required in order to obtain
2this information.
AB915,10,33 (c) Consent to the disclosure of this information.
AB915,10,44 (The principal and the witnesses all must sign the document at the same time.)
AB915,10,55 SIGNATURE OF PRINCIPAL
AB915,10,66 (person creating the power
AB915,10,77 of attorney for health care)
AB915,10,88 Signature.... Date....
AB915,10,109 (The signing of this document by the principal revokes all previous powers of
10attorney for health care documents.)
AB915,10,1111 STATEMENT OF WITNESSES
AB915,10,2112 I know the principal personally and I believe him or her to be of sound mind and
13at least 18 years of age. I believe that his or her execution of this power of attorney
14for health care is voluntary. I am at least 18 years of age, am not related to the
15principal by blood, marriage or adoption and am not directly financially responsible
16for the principal's health care. I am not a health care provider who is serving the
17principal at this time, an employe of the health care provider, other than a chaplain
18or a social worker, or an employe, other than a chaplain or a social worker, of an
19inpatient health care facility in which the declarant is a patient. I am not the
20principal's health care agent. To the best of my knowledge, I am not entitled to and
21do not have a claim on the principal's estate.
AB915,10,2222 Witness No. 1:
AB915,10,2323 (print) Name.... Date....
AB915,10,2424 Address....
AB915,10,2525 Signature....
AB915,11,1
1Witness No. 2:
AB915,11,22 (print) Name.... Date....
AB915,11,33 Address....
AB915,11,44 Signature....
AB915,11,55 STATEMENT OF HEALTH CARE AGENT
AB915,11,66 AND ALTERNATE HEALTH CARE AGENT
AB915,11,107 I understand that.... (name of principal) has designated me to be his or her
8health care agent or alternate health care agent if he or she is ever found to have
9incapacity and unable to make health care decisions himself or herself. .... (name of
10principal) has discussed his or her desires regarding health care decisions with me.
AB915,11,1111 Agent's signature....
AB915,11,1212 Address....
AB915,11,1313 Alternate's signature....
AB915,11,1414 Address....
AB915,11,1715 Failure to execute a power of attorney for health care document under chapter
16155 of the Wisconsin Statutes creates no presumption about the intent of any
17individual with regard to his or her health care decisions.
AB915,11,1918 This power of attorney for health care is executed as provided in chapter 155
19of the Wisconsin Statutes.
AB915,11,2020 ANATOMICAL GIFTS (optional)
AB915,11,2121 Upon my death:
AB915,11,2322 .... I wish to donate only the following organs or parts: .... (specify the organs or
23parts).
AB915,11,2424 .... I wish to donate any needed organ or part.
AB915,12,4
1.... I wish to donate my body for anatomical study if needed. (Since many
2institutions have certain conditions that must be met before receiving donation of a
3body, I will attempt to contact the institution to which the donation is intended to be
4made.)
AB915,12,75 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
6I have made to make an anatomical gift to a designated donee, I will attempt to notify
7the donee to which or to whom I agreed to donate.)
AB915,12,98 Failing to check any of the lines immediately above creates no presumption
9about my desire to make or refuse to make an anatomical gift.
AB915,12,1010 Signature.... Date....
AB915, s. 7 11Section 7. 155.30 (3m) of the statutes is created to read:
AB915,12,1412 155.30 (3m) The department may modify the form specified in sub. (3) to
13include, for the purposes of making an anatomical gift, the toll-free telephone
14number of the Wisconsin donor registry under s. 157.06 (10r).
AB915, s. 8 15Section 8. 157.06 (1) (c) 2. of the statutes is renumbered 157.06 (1) (c) and
16amended to read:
AB915,12,2017 157.06 (1) (c) "Document of gift" means a card, a statement attached to or
18imprinted on a license under s. 343.175 (2) or on an identification card under s.
19343.50 (3), a will, an enrollment form signed as specified in sub. (10r) (b) or another
20writing used to make an anatomical gift.
AB915, s. 9 21Section 9. 157.06 (1) (em) of the statutes is created to read:
AB915,12,2322 157.06 (1) (em) "Eye bank" means a repository for donated human eyes or
23portions of eyes destined for ocular transplant surgery and research.
AB915, s. 10 24Section 10. 157.06 (1) (km) of the statutes is created to read:
AB915,12,2525 157.06 (1) (km) "Tissue bank" means a repository for donated tissue and bone.
AB915, s. 11
1Section 11. 157.06 (2) (b) of the statutes is amended to read:
AB915,13,72 157.06 (2) (b) An anatomical gift under par. (a) may be made only by a document
3of gift signed and dated by the donor. If the donor cannot so sign and date, the
4document of gift shall be signed and dated by another individual and by 2 witnesses,
5all of whom have signed and dated at the direction and in the presence of the donor
6and of each other, and the document of gift shall state that it has been so signed and
7dated
.
AB915, s. 12 8Section 12. 157.06 (2) (f) 1. of the statutes is amended to read:
AB915,13,99 157.06 (2) (f) 1. Signing and dating a statement of amendment or revocation.
AB915, s. 13 10Section 13. 157.06 (2) (f) 1m. of the statutes is amended to read:
AB915,13,1311 157.06 (2) (f) 1m. Signing and dating a new document of gift. Signing and
12dating
a new document of gift revokes any previously signed and dated document of
13gift.
AB915, s. 14 14Section 14. 157.06 (2) (f) 4. of the statutes is amended to read:
AB915,13,1615 157.06 (2) (f) 4. Delivering a signed and dated statement of amendment or
16revocation to a specified donee to whom a document of gift had been delivered.
AB915, s. 15 17Section 15. 157.06 (2) (f) 5. b. of the statutes is renumbered 157.06 (2) (f) 5.
18and amended to read:
AB915,13,2119 157.06 (2) (f) 5. Crossing out or amending and dating the donor authorization
20or refusal in the space provided on his or her license as prescribed in s. 343.175 (2)
21or identification card as prescribed in s. 343.50 (3).
AB915, s. 16 22Section 16. 157.06 (2) (i) 1. of the statutes is amended to read:
AB915,13,2423 157.06 (2) (i) 1. Making a writing of refusal that is signed and dated in the same
24manner as is required for a document of gift.
AB915, s. 17 25Section 17. 157.06 (2) (i) 2. b. of the statutes is amended to read:
AB915,14,3
1157.06 (2) (i) 2. b. Attaching Dating and attaching a statement of refusal to or
2imprinting a statement of refusal on his or her license under s. 343.175 (2) or
3identification card under s. 343.50 (3).
AB915, s. 18 4Section 18. 157.06 (2) (i) 3. of the statutes is amended to read:
AB915,14,85 157.06 (2) (i) 3. Making and dating any other writing that is used to identify
6the individual as refusing to make an anatomical gift. During the individual's
7terminal illness or injury, he or she may make the refusal by an oral statement or
8other form of communication to another.
AB915, s. 19 9Section 19. 157.06 (2) (L) of the statutes is created to read:
AB915,14,1210 157.06 (2) (L) Notwithstanding the requirements for dating documents under
11pars. (b), (f) 1., 1m. 4. and 5. and (i) 1., 2. b. and 3. and s. 343.175 (2) (ar) and (b), and
12except as provided in ss. 155.10 (1) (b) and 155.40 (1) (b), all of the following apply:
AB915,14,1413 1. The existence of a document of gift in undated form does not invalidate the
14document of gift.
AB915,14,1615 2. The existence of a written but undated amendment to a document of gift does
16not invalidate the amendment.
AB915,14,1817 3. The existence of a written but undated revocation of an anatomical gift does
18not invalidate the revocation.
AB915,14,2019 4. The existence of a written but undated refusal to make an anatomical gift
20does not invalidate the refusal.
AB915,14,2221 5. The existence of a written but undated revocation of a refusal to make an
22anatomical gift does not invalidate the revocation of the refusal.
AB915, s. 20 23Section 20. 157.06 (10m) of the statutes is created to read:
AB915,14,2524 157.06 (10m) Donor registry board. (a) The donor registry board shall do all
25of the following:
AB915,15,8
11. Review requests for proposals and, from the appropriation under s. 20.435
2(1) (bm), award one or more contracts to establish, operate and maintain the
3Wisconsin donor registry. The board shall consult with the department in preparing
4requests for proposals under this subdivision. A contract under this subdivision
5shall specify that the awardee shall, at the end of the contract term or if the contract
6is otherwise terminated, relinquish to the board the names of enrollees and other
7information in the registry and any rights to a toll-free telephone number for the
8registry.
AB915,15,119 2. Direct and monitor or, from the appropriation under s. 20.435 (1) (bm), award
10a contract for the monitoring of the operation of and services provided by the
11Wisconsin donor registry.
AB915,15,1312 3. Promulgate rules that ensure the confidentiality of enrollees of the
13Wisconsin donor registry.
AB915,15,1614 4. Study the effectiveness of the Wisconsin donor registry and, by March 1,
152003, report the study results to the legislature under s. 13.172 (2) and to the
16governor.
AB915,15,1817 (b) The department of health and family services shall provide technical
18support to the donor registry board.
AB915, s. 21 19Section 21. 157.06 (10m) (a) 1. of the statutes, as created by 1999 Wisconsin
20Act .... (this act), is amended to read:
AB915,16,321 157.06 (10m) (a) 1. Review requests for proposals and, from the appropriation
22under s. 20.435 (1) (bm), award one or more contracts to establish, operate and
23maintain the Wisconsin donor registry. The board shall consult with the department
24in preparing requests for proposals under this subdivision. A contract under this
25subdivision shall specify that the awardee shall, at the end of the contract term or

1if the contract is otherwise terminated, relinquish to the board the names of enrollees
2and other information in the registry and any rights to a toll-free telephone number
3for the registry.
AB915, s. 22 4Section 22. 157.06 (10r) of the statutes is created to read:
AB915,16,125 157.06 (10r) Wisconsin donor registry. (a) Under a contract that is awarded
6under sub. (10m) (a) 1., an entity shall establish, operate and maintain an organ and
7tissue donor registry, to be known as the "Wisconsin donor registry", that includes
8the names of and pertinent information concerning persons who are enrolled to
9provide anatomical gifts. The entity may release information from the registry only
10to organ procurement organizations, eye banks, tissue banks, the donor registry
11board and its staff and any successor contractor. Information in the registry is not
12available for inspection or copying under s. 19.35 (1).
AB915,16,1813 (b) An individual who desires to make an anatomical gift and to be enrolled in
14the Wisconsin donor registry shall sign an enrollment form and return the form to
15the registry or to the department of transportation under s. 343.14 (6) (b) or 343.50
16(4m) (c). The enrollment form may be designed by the entity that operates and
17maintains the registry, but no form may conflict with the requirements of this
18section.
AB915,16,2319 (c) The entity that operates and maintains the Wisconsin donor registry shall
20operate a toll-free telephone number and may maintain an Internet Web site, to
21provide information about making an anatomical gift and about enrollment in and
22disenrollment from the registry. Any computer technology developed by the entity
23under this paragraph is the property of the donor registry board.
AB915,17,3
1(d) No organ procurement organization, tissue bank or eye bank may be
2required to contribute directly money or any other thing of value to provide payment
3for operation of the Wisconsin donor registry.
AB915, s. 23 4Section 23. 157.06 (10r) (a) of the statutes, as created by 1999 Wisconsin Act
5.... (this act), is amended to read:
AB915,17,136 157.06 (10r) (a) Under a contract that is awarded under sub. (10m) (a) 1., an
7entity shall establish, operate and maintain an organ and tissue donor registry, to
8be known as the "Wisconsin donor registry", that includes the names of and pertinent
9information concerning persons who are enrolled to provide anatomical gifts. The
10entity may release information from the registry only to organ procurement
11organizations, eye banks, tissue banks, the donor registry board and its staff and any
12successor contractor. Information in the registry is not available for inspection or
13copying under s. 19.35 (1).
AB915, s. 24 14Section 24. 343.14 (2) (g) 2m. of the statutes is created to read:
Loading...
Loading...