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INSPECTION AND DISCLOSURE OF INFORMATION
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RELATING TO MY PHYSICAL OR MENTAL HEALTH
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Subject to any limitations in this document, my health care agent has the
23authority to do all of the following:
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(a) Request, review and receive any information, oral or written, regarding my
25physical or mental health, including medical and hospital records.
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1(b) Execute on my behalf any documents that may be required in order to obtain
2this information.
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(c) Consent to the disclosure of this information.
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(The principal and the witnesses all must sign the document at the same time.)
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SIGNATURE OF PRINCIPAL
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(person creating the power
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of attorney for health care)
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Signature.... Date....
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(The signing of this document by the principal revokes all previous powers of
10attorney for health care documents.)
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STATEMENT OF WITNESSES
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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.
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Witness No. 1:
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(print) Name.... Date....
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Address....
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Signature....
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1Witness No. 2:
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(print) Name.... Date....
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Signature....
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STATEMENT OF HEALTH CARE AGENT
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AND ALTERNATE HEALTH CARE AGENT
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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.
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Agent's signature....
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Address....
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Alternate's signature....
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Address....
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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.
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This power of attorney for health care is executed as provided in chapter 155
19of the Wisconsin Statutes.
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ANATOMICAL GIFTS (optional)
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Upon my death:
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.... I wish to donate only the following organs or parts: .... (specify the organs or
23parts).
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.... I wish to donate any needed organ or part.
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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.)
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.... 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.)
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Failing to check any of the lines immediately above creates no presumption
9about my desire to make or refuse to make an anatomical gift.
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Signature....
Date....
SB488, s. 7
11Section
7. 155.30 (3m) of the statutes is created to read:
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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).
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15Section
8. 157.06 (1) (c) 2. of the statutes is renumbered 157.06 (1) (c) and
16amended to read:
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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.
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21Section
9. 157.06 (1) (em) of the statutes is created to read:
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157.06
(1) (em) "Eye bank" means a repository for donated human eyes or
23portions of eyes destined for ocular transplant surgery and research.
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24Section
10. 157.06 (1) (km) of the statutes is created to read:
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1157.06
(1) (km) "Tissue bank" means a repository for donated tissue and bone.
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2Section
11. 157.06 (2) (b) of the statutes is amended to read:
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157.06
(2) (b) An anatomical gift under par. (a) may be made only by a document
4of gift signed
and dated by the donor. If the donor cannot
so sign
and date, the
5document of gift shall be signed
and dated by another individual and by 2 witnesses,
6all of whom have signed
and dated at the direction and in the presence of the donor
7and of each other, and the document of gift shall state that it has been so signed
and
8dated.
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9Section
12. 157.06 (2) (f) 1. of the statutes is amended to read:
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157.06
(2) (f) 1. Signing
and dating a statement of amendment or revocation.
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11Section
13. 157.06 (2) (f) 1m. of the statutes is amended to read:
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157.06
(2) (f) 1m. Signing
and dating a new document of gift. Signing
and
13dating a new document of gift revokes any previously signed
and dated document of
14gift.
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15Section
14. 157.06 (2) (f) 4. of the statutes is amended to read:
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157.06
(2) (f) 4. Delivering a signed
and dated statement of amendment or
17revocation to a specified donee to whom a document of gift had been delivered.
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18Section
15. 157.06 (2) (f) 5. b. of the statutes is renumbered 157.06 (2) (f) 5.
19and amended to read:
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157.06
(2) (f) 5. Crossing out or amending
and dating the donor authorization
21or refusal in the space provided on his or her license as prescribed in s. 343.175 (2)
22or identification card as prescribed in s. 343.50 (3).
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23Section
16. 157.06 (2) (i) 1. of the statutes is amended to read:
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157.06
(2) (i) 1. Making a writing of refusal that is signed
and dated in the same
25manner as is required for a document of gift.
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1Section
17. 157.06 (2) (i) 2. b. of the statutes is amended to read:
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157.06
(2) (i) 2. b.
Attaching Dating and attaching a statement of refusal to or
3imprinting a statement of refusal on his or her license under s. 343.175 (2) or
4identification card under s. 343.50 (3).
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5Section
18. 157.06 (2) (i) 3. of the statutes is amended to read:
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157.06
(2) (i) 3. Making
and dating any other writing that is used to identify
7the individual as refusing to make an anatomical gift. During the individual's
8terminal illness or injury, he or she may make the refusal by an oral statement or
9other form of communication to another.
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10Section
19. 157.06 (2) (L) of the statutes is created to read:
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157.06
(2) (L) Notwithstanding the requirements for dating documents under
12pars. (b), (f) 1., 1m. 4. and 5. and (i) 1., 2. b. and 3. and s. 343.175 (2) (ar) and (b), and
13except as provided in ss. 155.10 (1) (b) and 155.40 (1) (b), all of the following apply:
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1. The existence of a document of gift in undated form does not invalidate the
15document of gift.
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2. The existence of a written but undated amendment to a document of gift does
17not invalidate the amendment.
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3. The existence of a written but undated revocation of an anatomical gift does
19not invalidate the revocation.
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4. The existence of a written but undated refusal to make an anatomical gift
21does not invalidate the refusal.
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5. The existence of a written but undated revocation of a refusal to make an
23anatomical gift does not invalidate the revocation of the refusal.
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24Section
20. 157.06 (10m) of the statutes is created to read:
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1157.06
(10m) Donor registry board. (a) The donor registry board shall do all
2of the following:
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1. Review requests for proposals and, from the appropriation under s. 20.435
4(1) (bm), award one or more contracts to establish, operate and maintain the
5Wisconsin donor registry. The board shall consult with the department in preparing
6requests for proposals under this subdivision. A contract under this subdivision
7shall specify that the awardee shall, at the end of the contract term or if the contract
8is otherwise terminated, relinquish to the board the names of enrollees and other
9information in the registry and any rights to a toll-free telephone number for the
10registry.
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2. Direct and monitor or, from the appropriation under s. 20.435 (1) (bm), award
12a contract for the monitoring of the operation of and services provided by the
13Wisconsin donor registry.
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3. Promulgate rules that ensure the confidentiality of enrollees of the
15Wisconsin donor registry.
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4. Study the effectiveness of the Wisconsin donor registry and, by March 1,
172003, report the study results to the legislature under s. 13.172 (2) and to the
18governor.
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(b) The department of health and family services shall provide technical
20support to the donor registry board.
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21Section
21. 157.06 (10m) (a) 1. of the statutes, as created by 1999 Wisconsin
22Act .... (this act), is amended to read:
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157.06
(10m) (a) 1. Review requests for proposals and, from the appropriation
24under s. 20.435 (1) (bm), award one or more contracts to
establish, operate and
25maintain the Wisconsin donor registry. The board shall consult with the department
1in preparing requests for proposals under this subdivision. A contract under this
2subdivision shall specify that the awardee shall, at the end of the contract term or
3if the contract is otherwise terminated, relinquish to the board the names of enrollees
4and other information in the registry and any rights to a toll-free telephone number
5for the registry.
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6Section
22. 157.06 (10r) of the statutes is created to read:
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157.06
(10r) Wisconsin donor registry. (a) Under a contract that is awarded
8under sub. (10m) (a) 1., an entity shall establish, operate and maintain an organ and
9tissue donor registry, to be known as the "Wisconsin donor registry", that includes
10the names of and pertinent information concerning persons who are enrolled to
11provide anatomical gifts. The entity may release information from the registry only
12to organ procurement organizations, eye banks, tissue banks, the donor registry
13board and its staff and any successor contractor. Information in the registry is not
14available for inspection or copying under s. 19.35 (1).
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(b) An individual who desires to make an anatomical gift and to be enrolled in
16the Wisconsin donor registry shall sign an enrollment form and return the form to
17the registry or to the department of transportation under s. 343.14 (6) (b) or 343.50
18(4m) (c). The enrollment form may be designed by the entity that operates and
19maintains the registry, but no form may conflict with the requirements of this
20section.
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(c) The entity that operates and maintains the Wisconsin donor registry shall
22operate a toll-free telephone number and may maintain an Internet Web site, to
23provide information about making an anatomical gift and about enrollment in and
24disenrollment from the registry. Any computer technology developed by the entity
25under this paragraph is the property of the donor registry board.
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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.
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4Section
23. 157.06 (10r) (a) of the statutes, as created by 1999 Wisconsin Act
5.... (this act), is amended to read:
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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).
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14Section
24. 343.14 (2) (g) 2m. of the statutes is created to read:
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343.14
(2) (g) 2m. The name and address of the applicant will be forwarded by
16the department to the Wisconsin donor registry under s. 157.06 (10r) (a) if the
17response to the question under this paragraph is affirmative.
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18Section
25. 343.14 (6) of the statutes is renumbered 343.14 (6) (a).