AB75,1302,2121 MAKING THIS DOCUMENT
AB75,1302,2522 YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH
23CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION,
24AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF
25YOU OBJECT.
AB75,1303,6
1BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT
2HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM
3RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR
4BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY
5RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY
6OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE.
AB75,1303,197 IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL
8DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE
9HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE
10DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH
11CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR
12THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE
13PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN
14THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT
15DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE
16AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES
17WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS
18REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN
19MAKING THE DECISION.
AB75,1304,820 THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT
21BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT
22REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU
23MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY
24FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY
25DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN

1YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY
2STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF
3YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE
4PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY.
5IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND YOUR
6MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR THE DOMESTIC
7PARTNERSHIP IS TERMINATED
AFTER SIGNING THIS DOCUMENT, THE
8DOCUMENT IS INVALID.
AB75,1304,159 YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE
10AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT
11TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT
12REVOKES ANY PRIOR RECORD OF GIFT THAT YOU MAY HAVE MADE. YOU
13MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY
14THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION
15IN THIS DOCUMENT.
AB75,1304,1716 DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND
17IT.
AB75,1304,1918 IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS
19DOCUMENT ON FILE WITH YOUR PHYSICIAN."
AB75, s. 2440 20Section 2440. 155.30 (3) (form) of the statutes is amended to read:
AB75,1304,2121 155.30 (3) (form)
AB75,1304,2222 POWER OF ATTORNEY FOR HEALTH CARE
AB75,1304,2323 Document made this.... day of.... (month),.... (year).
AB75,1304,2524 CREATION OF POWER OF ATTORNEY
25 FOR HEALTH CARE
AB75,1305,8
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.
AB75,1305,109 In addition, I may, by this document, specify my wishes with respect to making
10an anatomical gift upon my death.
AB75,1305,1111 DESIGNATION OF HEALTH CARE AGENT
AB75,1306,212 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 nor my
18alternate health care agent whom I have designated is my health care provider, an
19employee of my health care provider, an employee 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.
AB75,1306,33 GENERAL STATEMENT OF AUTHORITY GRANTED
AB75,1306,104 Unless I have specified otherwise in this document, if I ever have incapacity I
5instruct my health care provider to obtain the health care decision of my health care
6agent, if I need treatment, for all of my health care and treatment. I have discussed
7my desires thoroughly with my health care agent and believe that he or she
8understands my philosophy regarding the health care decisions I would make if I
9were able. I desire that my wishes be carried out through the authority given to my
10health care agent under this document.
AB75,1306,1911 If I am unable, due to my incapacity, to make a health care decision, my health
12care agent is instructed to make the health care decision for me, but my health care
13agent should try to discuss with me any specific proposed health care if I am able to
14communicate in any manner, including by blinking my eyes. If this communication
15cannot be made, my health care agent shall base his or her decision on any health
16care choices that I have expressed prior to the time of the decision. If I have not
17expressed a health care choice about the health care in question and communication
18cannot be made, my health care agent shall base his or her health care decision on
19what he or she believes to be in my best interest.
AB75,1306,2020 LIMITATIONS ON MENTAL HEALTH TREATMENT
AB75,1306,2521 My health care agent may not admit or commit me on an inpatient basis to an
22institution for mental diseases, an intermediate care facility for persons with mental
23retardation, a state treatment facility or a treatment facility. My health care agent
24may not consent to experimental mental health research or psychosurgery,
25electroconvulsive treatment or drastic mental health treatment procedures for me.
AB75,1307,2
1ADMISSION TO NURSING HOMES OR
2 COMMUNITY-BASED RESIDENTIAL FACILITIES
AB75,1307,43 My health care agent may admit me to a nursing home or community-based
4residential facility for short-term stays for recuperative care or respite care.
AB75,1307,75 If I have checked "Yes" to the following, my health care agent may admit me for
6a purpose other than recuperative care or respite care, but if I have checked "No" to
7the following, my health care agent may not so admit me:
AB75,1307,88 1. A nursing home — Yes.... No....
AB75,1307,99 2. A community-based residential facility — Yes.... No....
AB75,1307,1110 If I have not checked either "Yes" or "No" immediately above, my health care
11agent may admit me only for short-term stays for recuperative care or respite care.
AB75,1307,1212 PROVISION OF A FEEDING TUBE
AB75,1307,1713 If I have checked "Yes" to the following, my health care agent may have a
14feeding tube withheld or withdrawn from me, unless my physician has advised that,
15in his or her professional judgment, this will cause me pain or will reduce my comfort.
16If I have checked "No" to the following, my health care agent may not have a feeding
17tube withheld or withdrawn from me.
AB75,1307,2018 My health care agent may not have orally ingested nutrition or hydration
19withheld or withdrawn from me unless provision of the nutrition or hydration is
20medically contraindicated.
AB75,1307,2121 Withhold or withdraw a feeding tube — Yes.... No....
AB75,1307,2322 If I have not checked either "Yes" or "No" immediately above, my health care
23agent may not have a feeding tube withdrawn from me.
AB75,1307,2524 HEALTH CARE DECISIONS FOR
25 PREGNANT WOMEN
AB75,1308,4
1If I have checked "Yes" to the following, my health care agent may make health
2care decisions for me even if my agent knows I am pregnant. If I have checked "No"
3to the following, my health care agent may not make health care decisions for me if
4my health care agent knows I am pregnant.
AB75,1308,55 Health care decision if I am pregnant — Yes.... No....
AB75,1308,86 If I have not checked either "Yes" or "No" immediately above, my health care
7agent may not make health care decisions for me if my health care agent knows I am
8pregnant.
AB75,1308,109 STATEMENT OF DESIRES,
10 SPECIAL PROVISIONS OR LIMITATIONS
AB75,1308,1411 In exercising authority under this document, my health care agent shall act
12consistently with my following stated desires, if any, and is subject to any special
13provisions or limitations that I specify. The following are specific desires, provisions
14or limitations that I wish to state (add more items if needed):
AB75,1308,1515 1) -
AB75,1308,1616 2) -
AB75,1308,1717 3) -
AB75,1308,2018 INSPECTION AND DISCLOSURE OF
19 INFORMATION RELATING TO MY PHYSICAL
20 OR MENTAL HEALTH
AB75,1308,2221 Subject to any limitations in this document, my health care agent has the
22authority to do all of the following:
AB75,1308,2423 (a) Request, review and receive any information, oral or written, regarding my
24physical or mental health, including medical and hospital records.
AB75,1309,2
1(b) Execute on my behalf any documents that may be required in order to obtain
2this information.
AB75,1309,33 (c) Consent to the disclosure of this information.
AB75,1309,44 (The principal and the witnesses all must sign the document at the same time.)
AB75,1309,55 SIGNATURE OF PRINCIPAL
AB75,1309,66 (person creating the power of attorney for health care)
AB75,1309,77 Signature....  Date....
AB75,1309,98 (The signing of this document by the principal revokes all previous powers of
9attorney for health care documents.)
AB75,1309,1010 STATEMENT OF WITNESSES
AB75,1309,2111 I know the principal personally and I believe him or her to be of sound mind and
12at least 18 years of age. I believe that his or her execution of this power of attorney
13for health care is voluntary. I am at least 18 years of age, am not related to the
14principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
15of the principal,
and am not directly financially responsible for the principal's health
16care. I am not a health care provider who is serving the principal at this time, an
17employee of the health care provider, other than a chaplain or a social worker, or an
18employee, other than a chaplain or a social worker, of an inpatient health care facility
19in which the declarant is a patient. I am not the principal's health care agent. To
20the best of my knowledge, I am not entitled to and do not have a claim on the
21principal's estate.
AB75,1309,2222 Witness No. 1:
AB75,1309,2323 (print) Name.... Date....
AB75,1309,2424 Address....
AB75,1309,2525 Signature....
AB75,1310,1
1Witness No. 2:
AB75,1310,22 (print) Name.... Date....
AB75,1310,33 Address....
AB75,1310,44 Signature....
AB75,1310,65 STATEMENT OF HEALTH CARE AGENT AND
6 ALTERNATE HEALTH CARE AGENT
AB75,1310,107 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.
AB75,1310,1111 Agent's signature....
AB75,1310,1212 Address....
AB75,1310,1313 Alternate's signature....
AB75,1310,1414 Address....
AB75,1310,1715 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.
AB75,1310,1918 This power of attorney for health care is executed as provided in chapter 155
19of the Wisconsin Statutes.
AB75,1310,2020 ANATOMICAL GIFTS (optional)
AB75,1310,2121 Upon my death:
AB75,1310,2322 .... I wish to donate only the following organs or parts: .... (specify the organs or
23parts).
AB75,1310,2424 .... I wish to donate any needed organ or part.
AB75,1310,2525 .... I wish to donate my body for anatomical study if needed.
AB75,1311,3
1.... I refuse to make an anatomical gift. (If this revokes a prior commitment that
2I have made to make an anatomical gift to a designated donee, I will attempt to notify
3the donee to which or to whom I agreed to donate.)
AB75,1311,54 Failing to check any of the lines immediately above creates no presumption
5about my desire to make or refuse to make an anatomical gift.
AB75,1311,66 Signature....     Date....
AB75, s. 2441 7Section 2441. 155.40 (2) of the statutes is amended to read:
AB75,1311,128 155.40 (2) If the health care agent is the principal's spouse or domestic partner
9under ch. 770
and, subsequent to the execution of a power of attorney for health care
10instrument, the marriage is annulled or divorce from the spouse is obtained or the
11domestic partnership under ch. 770 is terminated
, the power of attorney for health
12care is revoked and the power of attorney for health care instrument is invalid.
AB75, s. 2442 13Section 2442. 157.05 of the statutes is amended to read:
AB75,1311,20 14157.05 Autopsy. Consent for a licensed physician to conduct an autopsy on
15the body of a deceased person shall be deemed sufficient when given by whichever
16one of the following assumes custody of the body for purposes of burial: Father,
17mother, husband, wife, child, guardian, next of kin, domestic partner under ch. 770,
18or in the absence of any of the foregoing, a friend, or a person charged by law with
19the responsibility for burial. If 2 or more such persons assume custody of the body,
20the consent of one of them shall be deemed sufficient.
AB75, s. 2443 21Section 2443. 157.06 (9) (a) 2. of the statutes is amended to read:
AB75,1311,2222 157.06 (9) (a) 2. The spouse or domestic partner under ch. 770 of the individual.
AB75, s. 2444 23Section 2444. 165.25 (4) (ar) of the statutes is amended to read:
AB75,1312,424 165.25 (4) (ar) The department of justice shall furnish all legal services
25required by the department of agriculture, trade and consumer protection relating

1to the enforcement of ss. 91.68, 93.73, 100.171, 100.173, 100.174, 100.175, 100.177,
2100.18, 100.182, 100.195, 100.20, 100.205, 100.207, 100.209, 100.21, 100.28, 100.37,
3100.42, 100.50, and 100.51, and 100.55, and chs. 126, 136, 344, 704, 707, and 779,
4together with any other services as are necessarily connected to the legal services.
AB75, s. 2445 5Section 2445. 165.60 of the statutes is amended to read:
AB75,1312,12 6165.60 Law enforcement. The department of justice is authorized to enforce
7ss. 101.123 (2), (5), (2m), and (8), 944.30, 944.31, 944.33, 944.34, 945.02 (2), 945.03
8(1m), and 945.04 (1m) and ch. 108 and is invested with the powers conferred by law
9upon sheriffs and municipal police officers in the performance of those duties. This
10section does not deprive or relieve sheriffs, constables, and other local police officers
11of the power and duty to enforce those sections, and those officers shall likewise
12enforce those sections.
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