AB861,11,65
STATEMENT OF DESIRES, SPECIAL
6
PROVISIONS OR LIMITATIONS
AB861,11,107
In exercising authority under this document, my health care agent shall act
8consistently with my following stated desires, if any, and is subject to any special
9provisions or limitations that I specify. The following are specific desires, provisions
10or limitations that I wish to state (add more items if needed):
AB861,11,1614
INSPECTION AND DISCLOSURE OF
15
INFORMATION RELATING TO MY
16
PHYSICAL OR MENTAL HEALTH
AB861,11,1817
Subject to any limitations in this document, my health care agent has the
18authority to do all of the following:
AB861,11,2019
(a) Request, review and receive any information, oral or written, regarding my
20physical or mental health, including medical and hospital records.
AB861,11,2221
(b) Execute on my behalf any documents that may be required in order to obtain
22this information.
AB861,11,2323
(c) Consent to the disclosure of this information.
AB861,11,2424
(The principal and the witnesses all must sign the document at the same time.)
AB861,11,2525
SIGNATURE OF PRINCIPAL
AB861,12,1
1(person creating the power of attorney for health care)
AB861,12,22
Signature.... Date....
AB861,12,43
(The signing of this document by the principal revokes all previous powers of
4attorney for health care documents.)
AB861,12,55
STATEMENT OF WITNESSES
AB861,12,166
I know the principal personally and I believe him or her to be of sound mind and
7at least 18 years of age. I believe that his or her execution of this power of attorney
8for health care is voluntary. I am at least 18 years of age, am not related to the
9principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
10of the principal, and am not directly financially responsible for the principal's health
11care. I am not a health care provider who is serving the principal at this time, an
12employee of the health care provider, other than a chaplain or a social worker, or an
13employee, other than a chaplain or a social worker, of an inpatient health care facility
14in which the declarant is a patient. I am not the principal's health care agent. To
15the best of my knowledge, I am not entitled to and do not have a claim on the
16principal's estate.
AB861,12,1717
Witness No. 1:
AB861,12,1818
(print) Name.... Date....
AB861,12,1919
Address....
AB861,12,2020
Signature....
AB861,12,2121
Witness No. 2:
AB861,12,2222
(print) Name.... Date....
AB861,12,2323
Address....
AB861,12,2424
Signature....
AB861,13,2
1STATEMENT OF HEALTH CARE AGENT
2
AND ALTERNATE HEALTH CARE AGENT
AB861,13,63
I understand that.... (name of principal) has designated me to be his or her
4health care agent or alternate health care agent if he or she is ever found to have
5incapacity and unable to make health care decisions himself or herself. .... (name of
6principal) has discussed his or her desires regarding health care decisions with me.
AB861,13,77
Agent's signature....
AB861,13,99
Alternate's signature....
AB861,13,1010
Address....
AB861,13,1311
Failure to execute a power of attorney for health care document under chapter
12155 of the Wisconsin Statutes creates no presumption about the intent of any
13individual with regard to his or her health care decisions.
AB861,13,1514
This power of attorney for health care is executed as provided in chapter 155
15of the Wisconsin Statutes.
AB861,13,1616
ANATOMICAL GIFTS (optional)
AB861,13,1717
Upon my death:
AB861,13,1918
.... I wish to donate only the following organs or parts: .... (specify the organs or
19parts).
AB861,13,2020
.... I wish to donate any needed organ or part.
AB861,13,2121
.... I wish to donate my body for anatomical study if needed.
AB861,13,2422
.... I refuse to make an anatomical gift. (If this revokes a prior commitment that
23I have made to make an anatomical gift to a designated donee, I will attempt to notify
24the donee to which or to whom I agreed to donate.)
AB861,14,2
1Failing to check any of the lines immediately above creates no presumption
2about my desire to make or refuse to make an anatomical gift.
AB861,14,33
Signature.... Date....
AB861,7
4Section
7.
Initial applicability.
AB861,14,75
(1) This act first applies to declarations to physicians, do-not-resuscitate
6orders, and power of attorney for health care instruments executed on the effective
7date of this subsection.
AB861,8
8Section
8.
Effective date.
AB861,14,109
(1)
This act takes effect on the first day of the 4th month beginning after
10publication.
