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(print) Name.... Date....
AB861,12,1919
Address....
AB861,12,2020
Signature....
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Witness No. 2:
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(print) Name.... Date....
AB861,12,2323
Address....
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Signature....
AB861,13,2
1STATEMENT OF HEALTH CARE AGENT
2
AND ALTERNATE HEALTH CARE AGENT
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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....
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Alternate's signature....
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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.
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This power of attorney for health care is executed as provided in chapter 155
15of 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
19parts).
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.... I wish to donate any needed organ or part.
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.... I wish to donate my body for anatomical study if needed.
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.... 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.
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(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.
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(1)
This act takes effect on the first day of the 4th month beginning after
10publication.
