AB695: Bill Text

AB695,22,2 My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for persons with an intellectual disability, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me.

AB695,22,4 ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES

AB695,22,6 My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care.

AB695,22,9 If I have checked "Yes" to the following, my health care agent may admit me for a purpose other than recuperative care or respite care, but if I have checked "No" to the following, my health care agent may not so admit me:

AB695,22,10 1. A nursing home — Yes.... No....

AB695,22,11 2. A community-based residential facility — Yes.... No....

AB695,22,13 If I have not checked either "Yes" or "No" immediately above, my health care agent may admit me only for short-term stays for recuperative care or respite care.

AB695,22,14 PROVISION OF A FEEDING TUBE

AB695,22,19 If I have checked "Yes" to the following, my health care agent may have a feeding tube withheld or withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort. If I have checked "No" to the following, my health care agent may not have a feeding tube withheld or withdrawn from me.

AB695,22,22 My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated.

AB695,22,23 Withhold or withdraw a feeding tube — Yes.... No....

AB695,22,25 If I have not checked either "Yes" or "No" immediately above, my health care agent may not have a feeding tube withdrawn from me.

AB695,23,2 HEALTH CARE DECISIONS FOR PREGNANT WOMEN

AB695,23,6 If I have checked "Yes" to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked "No" to the following, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.

AB695,23,7 Health care decision if I am pregnant — Yes.... No....

AB695,23,10 If I have not checked either "Yes" or "No" immediately above, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.

AB695,23,11 ACCESS TO DIGITAL ASSETS

AB695,23,15 If I have checked "Yes" to the following, my health care agent may access the content of electronic communications on my behalf. If I have checked "No" to the following, my health care agent may not access the content of electronic communications on my behalf.

AB695,23,16 Access to content of electronic communications — Yes.... No....

AB695,23,18 If I have not checked either "Yes" or "No" immediately above, my agent may not access the content of electronic communications on my behalf.

AB695,23,20 STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS

AB695,23,24 In exercising authority under this document, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are specific desires, provisions or limitations that I wish to state (add more items if needed):

AB695,23,25 1) -

AB695,24,1 2) -

AB695,24,2 3) -

AB695,24,5 INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH

AB695,24,7 Subject to any limitations in this document, my health care agent has the authority to do all of the following:

AB695,24,9 (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records.

AB695,24,11 (b) Execute on my behalf any documents that may be required in order to obtain this information.

AB695,24,12 (c) Consent to the disclosure of this information.

AB695,24,14 (d) Access my digital assets, other than the content of my electronic communication, and catalogues of my electronic communications.

AB695,24,15 (The principal and the witnesses all must sign the document at the same time.)

AB695,24,16 SIGNATURE OF PRINCIPAL

AB695,24,17 (person creating the power of attorney for health care)

AB695,24,18 Signature....  Date....

AB695,24,20 (The signing of this document by the principal revokes all previous powers of attorney for health care documents.)

AB695,24,21 STATEMENT OF WITNESSES

AB695,25,7 I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage, or adoption, am not the domestic partner under ch. 770 of the principal, and am not directly financially responsible for the principal's health care. I am not a health care provider who is serving the principal at this time, an employee of the health care provider, other than a chaplain or a social worker, or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do not have a claim on the principal's estate.

AB695,25,8 Witness No. 1:

AB695,25,9 (print) Name.... Date....

AB695,25,10 Address....

AB695,25,11 Signature....

AB695,25,12 Witness No. 2:

AB695,25,13 (print) Name.... Date....

AB695,25,14 Address....

AB695,25,15 Signature....

AB695,25,17 STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT

AB695,25,21 I understand that.... (name of principal) has designated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. .... (name of principal) has discussed his or her desires regarding health care decisions with me.

AB695,25,22 Agent's signature....

AB695,25,23 Address....

AB695,25,24 Alternate's signature....

AB695,25,25 Address....

AB695,26,3 Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or her health care decisions.

AB695,26,5 This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes.

AB695,26,6 ANATOMICAL GIFTS (optional)

AB695,26,7 Upon my death:

AB695,26,9 .... I wish to donate only the following organs or parts: .... (specify the organs or parts).

AB695,26,10 .... I wish to donate any needed organ or part.

AB695,26,11 .... I wish to donate my body for anatomical study if needed.

AB695,26,14 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to whom I agreed to donate.)

AB695,26,16 Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift.

AB695,26,17 Signature....     Date....

AB695,5 Section 5. 244.41 (1) (i) of the statutes is created to read:

AB695,26,20 244.41 (1) (i) Access the content of an electronic communication, as defined in s. 112.12 (2) (f), sent or received by the principal.

AB695,6 Section 6. 244.43 (9m) of the statutes is created to read:

AB695,26,25 244.43 (9m) Access a catalogue of electronic communications, as defined in s. 112.12 (2) (d), sent or received by the principal, and the principal's digital assets, as defined in s. 112.12 (2) (j), other than the content of electronic communications, as defined in s. 112.12 (2) (f).

AB695,7 Section 7. 244.61 (form) of the statutes is amended to read:

AB695,27,2 244.61 (form)

AB695,27,5 WISCONSIN STATUTORY FORM POWER OF ATTORNEY FOR FINANCES AND PROPERTY

AB695,27,6 IMPORTANT INFORMATION

AB695,27,14 THIS POWER OF ATTORNEY AUTHORIZES ANOTHER PERSON (YOUR AGENT) TO MAKE DECISIONS CONCERNING YOUR PROPERTY FOR YOU (THE PRINCIPAL). YOUR AGENT WILL BE ABLE TO MAKE DECISIONS AND ACT WITH RESPECT TO YOUR PROPERTY (INCLUDING YOUR MONEY) WHETHER OR NOT YOU ARE ABLE TO ACT FOR YOURSELF. THE MEANING OF AUTHORITY OVER SUBJECTS LISTED ON THIS FORM IS EXPLAINED IN THE UNIFORM POWER OF ATTORNEY FOR FINANCES AND PROPERTY ACT IN CHAPTER 244 OF THE WISCONSIN STATUTES.

AB695,27,16 THIS POWER OF ATTORNEY DOES NOT AUTHORIZE THE AGENT TO MAKE HEALTH-CARE DECISIONS FOR YOU.

AB695,27,20 YOU SHOULD SELECT SOMEONE YOU TRUST TO SERVE AS YOUR AGENT. UNLESS YOU SPECIFY OTHERWISE, GENERALLY THE AGENT'S AUTHORITY WILL CONTINUE UNTIL YOU DIE OR REVOKE THE POWER OF ATTORNEY OR THE AGENT RESIGNS OR IS UNABLE TO ACT FOR YOU.

AB695,27,22 YOUR AGENT IS ENTITLED TO REASONABLE COMPENSATION UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.

AB695,28,2 THIS FORM PROVIDES FOR DESIGNATION OF ONE AGENT. IF YOU WISH TO NAME MORE THAN ONE AGENT YOU MAY NAME A COAGENT IN THE SPECIAL INSTRUCTIONS. COAGENTS ARE NOT REQUIRED TO ACT TOGETHER UNLESS YOU INCLUDE THAT REQUIREMENT IN THE SPECIAL INSTRUCTIONS.

AB695,28,5 IF YOUR AGENT IS UNABLE OR UNWILLING TO ACT FOR YOU, YOUR POWER OF ATTORNEY WILL END UNLESS YOU HAVE NAMED A SUCCESSOR AGENT. YOU MAY ALSO NAME A 2ND SUCCESSOR AGENT.

AB695,28,10 THIS POWER OF ATTORNEY BECOMES EFFECTIVE IMMEDIATELY UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS. THIS POWER OF ATTORNEY DOES NOT REVOKE ANY POWER OF ATTORNEY EXECUTED PREVIOUSLY UNLESS YOU SO PROVIDE IN THE SPECIAL INSTRUCTIONS.

AB695,28,16 IF YOU REVOKE THIS POWER OF ATTORNEY, YOU SHOULD NOTIFY YOUR AGENT AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR LEGALLY SEPARATED OR THE DOMESTIC PARTNERSHIP IS TERMINATED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.

AB695,28,19 IF YOU HAVE QUESTIONS ABOUT THE POWER OF ATTORNEY OR THE AUTHORITY YOU ARE GRANTING TO YOUR AGENT, YOU SHOULD SEEK LEGAL ADVICE BEFORE SIGNING THIS FORM.

AB695,28,20 DESIGNATION OF AGENT

AB695,28,21 I .... (name of principal) name the following person as my agent:

AB695,28,22 Name of agent: ....

AB695,28,23 Agent's address: ....

AB695,28,24 Agent's telephone number: ....

AB695,28,25 DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)

AB695,29,1 If my agent is unable or unwilling to act for me, I name as my successor agent:

AB695,29,2 Name of successor agent: ....

AB695,29,3 Successor agent's address: ....

AB695,29,4 Successor agent's telephone number: ....