AB75-SSA1, s. 2436n 24Section 2436n. 153.01 (4t) of the statutes is amended to read:
AB75-SSA1,1298,2
1153.01 (4t) "Health care provider" has the meaning given in s. 146.81 (1) (a)
2to (p)
and includes an ambulatory surgery center.
AB75-SSA1, s. 2437 3Section 2437. 155.01 (12) of the statutes is repealed and recreated to read:
AB75-SSA1,1298,84 155.01 (12) "Relative" means an individual related by blood within the 3rd
5degree of kinship as computed under s. 990.001 (16); a spouse, domestic partner
6under ch. 770, or an individual related to a spouse or domestic partner within the 3rd
7degree as so computed; and includes an individual in an adoptive relationship within
8the 3rd degree.
AB75-SSA1, s. 2438 9Section 2438. 155.10 (2) (a) of the statutes is amended to read:
AB75-SSA1,1298,1110 155.10 (2) (a) Related to the principal by blood, marriage, or adoption, or the
11domestic partner under ch. 770 of the individual
.
AB75-SSA1, s. 2439 12Section 2439. 155.30 (1) (form) of the statutes is amended to read:
AB75-SSA1,1298,1313 155.30 (1) (form)
AB75-SSA1,1298,14 14"NOTICE TO PERSON
AB75-SSA1,1298,1515 MAKING THIS DOCUMENT
AB75-SSA1,1298,1916 YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH
17CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION,
18AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF
19YOU OBJECT.
AB75-SSA1,1298,2520 BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT
21HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM
22RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR
23BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY
24RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY
25OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE.
AB75-SSA1,1299,13
1IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL
2DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE
3HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE
4DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH
5CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR
6THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE
7PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN
8THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT
9DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE
10AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES
11WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS
12REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN
13MAKING THE DECISION.
AB75-SSA1,1300,214 THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT
15BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT
16REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU
17MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY
18FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY
19DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN
20YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY
21STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF
22YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE
23PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY.
24IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND YOUR
25MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR THE DOMESTIC

1PARTNERSHIP IS TERMINATED
AFTER SIGNING THIS DOCUMENT, THE
2DOCUMENT IS INVALID.
AB75-SSA1,1300,93 YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE
4AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT
5TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT
6REVOKES ANY PRIOR RECORD OF GIFT THAT YOU MAY HAVE MADE. YOU
7MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY
8THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION
9IN THIS DOCUMENT.
AB75-SSA1,1300,1110 DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND
11IT.
AB75-SSA1,1300,1312 IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS
13DOCUMENT ON FILE WITH YOUR PHYSICIAN."
AB75-SSA1, s. 2440 14Section 2440. 155.30 (3) (form) of the statutes is amended to read:
AB75-SSA1,1300,1515 155.30 (3) (form)
AB75-SSA1,1300,1616 POWER OF ATTORNEY FOR HEALTH CARE
AB75-SSA1,1300,1717 Document made this.... day of.... (month),.... (year).
AB75-SSA1,1300,1918 CREATION OF POWER OF ATTORNEY
19 FOR HEALTH CARE
AB75-SSA1,1301,220 I,.... (print name, address and date of birth), being of sound mind, intend by this
21document to create a power of attorney for health care. My executing this power of
22attorney for health care is voluntary. Despite the creation of this power of attorney
23for health care, I expect to be fully informed about and allowed to participate in any
24health care decision for me, to the extent that I am able. For the purposes of this
25document, "health care decision" means an informed decision to accept, maintain,

1discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
2or treat my physical or mental condition.
AB75-SSA1,1301,43 In addition, I may, by this document, specify my wishes with respect to making
4an anatomical gift upon my death.
AB75-SSA1,1301,55 DESIGNATION OF HEALTH CARE AGENT
AB75-SSA1,1301,206 If I am no longer able to make health care decisions for myself, due to my
7incapacity, I hereby designate.... (print name, address and telephone number) to be
8my health care agent for the purpose of making health care decisions on my behalf.
9If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
10address and telephone number) to be my alternate health care agent for the purpose
11of making health care decisions on my behalf. Neither my health care agent nor my
12alternate health care agent whom I have designated is my health care provider, an
13employee of my health care provider, an employee of a health care facility in which
14I am a patient or a spouse of any of those persons, unless he or she is also my relative.
15For purposes of this document, "incapacity" exists if 2 physicians or a physician and
16a psychologist who have personally examined me sign a statement that specifically
17expresses their opinion that I have a condition that means that I am unable to receive
18and evaluate information effectively or to communicate decisions to such an extent
19that I lack the capacity to manage my health care decisions. A copy of that statement
20must be attached to this document.
AB75-SSA1,1301,2121 GENERAL STATEMENT OF AUTHORITY GRANTED
AB75-SSA1,1302,322 Unless I have specified otherwise in this document, if I ever have incapacity I
23instruct my health care provider to obtain the health care decision of my health care
24agent, if I need treatment, for all of my health care and treatment. I have discussed
25my desires thoroughly with my health care agent and believe that he or she

1understands my philosophy regarding the health care decisions I would make if I
2were able. I desire that my wishes be carried out through the authority given to my
3health care agent under this document.
AB75-SSA1,1302,124 If I am unable, due to my incapacity, to make a health care decision, my health
5care agent is instructed to make the health care decision for me, but my health care
6agent should try to discuss with me any specific proposed health care if I am able to
7communicate in any manner, including by blinking my eyes. If this communication
8cannot be made, my health care agent shall base his or her decision on any health
9care choices that I have expressed prior to the time of the decision. If I have not
10expressed a health care choice about the health care in question and communication
11cannot be made, my health care agent shall base his or her health care decision on
12what he or she believes to be in my best interest.
AB75-SSA1,1302,1313 LIMITATIONS ON MENTAL HEALTH TREATMENT
AB75-SSA1,1302,1814 My health care agent may not admit or commit me on an inpatient basis to an
15institution for mental diseases, an intermediate care facility for persons with mental
16retardation, a state treatment facility or a treatment facility. My health care agent
17may not consent to experimental mental health research or psychosurgery,
18electroconvulsive treatment or drastic mental health treatment procedures for me.
AB75-SSA1,1302,2019 ADMISSION TO NURSING HOMES OR
20 COMMUNITY-BASED RESIDENTIAL FACILITIES
AB75-SSA1,1302,2221 My health care agent may admit me to a nursing home or community-based
22residential facility for short-term stays for recuperative care or respite care.
AB75-SSA1,1302,2523 If I have checked "Yes" to the following, my health care agent may admit me for
24a purpose other than recuperative care or respite care, but if I have checked "No" to
25the following, my health care agent may not so admit me:
AB75-SSA1,1302,26
11. A nursing home — Yes.... No....
AB75-SSA1,1303,22 2. A community-based residential facility — Yes.... No....
AB75-SSA1,1303,43 If I have not checked either "Yes" or "No" immediately above, my health care
4agent may admit me only for short-term stays for recuperative care or respite care.
AB75-SSA1,1303,55 PROVISION OF A FEEDING TUBE
AB75-SSA1,1303,106 If I have checked "Yes" to the following, my health care agent may have a
7feeding tube withheld or withdrawn from me, unless my physician has advised that,
8in his or her professional judgment, this will cause me pain or will reduce my comfort.
9If I have checked "No" to the following, my health care agent may not have a feeding
10tube withheld or withdrawn from me.
AB75-SSA1,1303,1311 My health care agent may not have orally ingested nutrition or hydration
12withheld or withdrawn from me unless provision of the nutrition or hydration is
13medically contraindicated.
AB75-SSA1,1303,1414 Withhold or withdraw a feeding tube — Yes.... No....
AB75-SSA1,1303,1615 If I have not checked either "Yes" or "No" immediately above, my health care
16agent may not have a feeding tube withdrawn from me.
AB75-SSA1,1303,1817 HEALTH CARE DECISIONS FOR
18 PREGNANT WOMEN
AB75-SSA1,1303,2219 If I have checked "Yes" to the following, my health care agent may make health
20care decisions for me even if my agent knows I am pregnant. If I have checked "No"
21to the following, my health care agent may not make health care decisions for me if
22my health care agent knows I am pregnant.
AB75-SSA1,1303,2323 Health care decision if I am pregnant — Yes.... No....
AB75-SSA1,1304,3
1If I have not checked either "Yes" or "No" immediately above, my health care
2agent may not make health care decisions for me if my health care agent knows I am
3pregnant.
AB75-SSA1,1304,54 STATEMENT OF DESIRES,
5 SPECIAL PROVISIONS OR LIMITATIONS
AB75-SSA1,1304,96 In exercising authority under this document, my health care agent shall act
7consistently with my following stated desires, if any, and is subject to any special
8provisions or limitations that I specify. The following are specific desires, provisions
9or limitations that I wish to state (add more items if needed):
AB75-SSA1,1304,1513 INSPECTION AND DISCLOSURE OF
14 INFORMATION RELATING TO MY PHYSICAL
15 OR MENTAL HEALTH
AB75-SSA1,1304,1716 Subject to any limitations in this document, my health care agent has the
17authority to do all of the following:
AB75-SSA1,1304,1918 (a) Request, review and receive any information, oral or written, regarding my
19physical or mental health, including medical and hospital records.
AB75-SSA1,1304,2120 (b) Execute on my behalf any documents that may be required in order to obtain
21this information.
AB75-SSA1,1304,2222 (c) Consent to the disclosure of this information.
AB75-SSA1,1304,2323 (The principal and the witnesses all must sign the document at the same time.)
AB75-SSA1,1304,2424 SIGNATURE OF PRINCIPAL
AB75-SSA1,1304,2525 (person creating the power of attorney for health care)
AB75-SSA1,1304,26
1Signature....  Date....
AB75-SSA1,1305,32 (The signing of this document by the principal revokes all previous powers of
3attorney for health care documents.)
AB75-SSA1,1305,44 STATEMENT OF WITNESSES
AB75-SSA1,1305,155 I know the principal personally and I believe him or her to be of sound mind and
6at least 18 years of age. I believe that his or her execution of this power of attorney
7for health care is voluntary. I am at least 18 years of age, am not related to the
8principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
9of the principal,
and am not directly financially responsible for the principal's health
10care. I am not a health care provider who is serving the principal at this time, an
11employee of the health care provider, other than a chaplain or a social worker, or an
12employee, other than a chaplain or a social worker, of an inpatient health care facility
13in which the declarant is a patient. I am not the principal's health care agent. To
14the best of my knowledge, I am not entitled to and do not have a claim on the
15principal's estate.
AB75-SSA1,1305,1616 Witness No. 1:
AB75-SSA1,1305,1717 (print) Name.... Date....
AB75-SSA1,1305,1818 Address....
AB75-SSA1,1305,1919 Signature....
AB75-SSA1,1305,2020 Witness No. 2:
AB75-SSA1,1305,2121 (print) Name.... Date....
AB75-SSA1,1305,2222 Address....
AB75-SSA1,1305,2323 Signature....
AB75-SSA1,1305,2524 STATEMENT OF HEALTH CARE AGENT AND
25 ALTERNATE HEALTH CARE AGENT
AB75-SSA1,1306,4
1I understand that.... (name of principal) has designated me to be his or her
2health care agent or alternate health care agent if he or she is ever found to have
3incapacity and unable to make health care decisions himself or herself. .... (name of
4principal) has discussed his or her desires regarding health care decisions with me.
AB75-SSA1,1306,55 Agent's signature....
AB75-SSA1,1306,66 Address....
AB75-SSA1,1306,77 Alternate's signature....
AB75-SSA1,1306,88 Address....
AB75-SSA1,1306,119 Failure to execute a power of attorney for health care document under chapter
10155 of the Wisconsin Statutes creates no presumption about the intent of any
11individual with regard to his or her health care decisions.
AB75-SSA1,1306,1312 This power of attorney for health care is executed as provided in chapter 155
13of the Wisconsin Statutes.
AB75-SSA1,1306,1414 ANATOMICAL GIFTS (optional)
AB75-SSA1,1306,1515 Upon my death:
AB75-SSA1,1306,1716 .... I wish to donate only the following organs or parts: .... (specify the organs or
17parts).
AB75-SSA1,1306,1818 .... I wish to donate any needed organ or part.
AB75-SSA1,1306,1919 .... I wish to donate my body for anatomical study if needed.
AB75-SSA1,1306,2220 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
21I have made to make an anatomical gift to a designated donee, I will attempt to notify
22the donee to which or to whom I agreed to donate.)
AB75-SSA1,1306,2423 Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
AB75-SSA1,1306,2525 Signature....     Date....
AB75-SSA1, s. 2441
1Section 2441. 155.40 (2) of the statutes is amended to read:
AB75-SSA1,1307,62 155.40 (2) If the health care agent is the principal's spouse or domestic partner
3under ch. 770
and, subsequent to the execution of a power of attorney for health care
4instrument, the marriage is annulled or divorce from the spouse is obtained or the
5domestic partnership under ch. 770 is terminated
, the power of attorney for health
6care is revoked and the power of attorney for health care instrument is invalid.
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