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INSPECTION AND DISCLOSURE OF
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INFORMATION RELATING TO MY
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PHYSICAL OR MENTAL HEALTH
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1Subject to any limitations in this document, my health care agent has the
2authority to do all of the following:
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(a) Request, review and receive any information,
verbal oral or written,
4regarding my physical or mental health, including medical and hospital records.
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(b) Execute on my behalf any documents that may be required in order to obtain
6this information.
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(c) Consent to the disclosure of this information.
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(The principal and the witnesses all must sign the document at the same time.)
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SIGNATURE OF PRINCIPAL
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(person creating the power
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of attorney for health care)
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Signature
.... Date
....
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(The signing of this document by the principal revokes all previous powers of
14attorney for health care documents.)
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STATEMENT OF WITNESSES
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I know the principal personally and I believe him or her to be of sound mind and
17at least 18 years of age. I believe that his or her execution of this power of attorney
18for health care is voluntary. I am at least 18 years of age, am not related to the
19principal by blood, marriage or adoption and am not directly financially responsible
20for the principal's health care. I am not a health care provider who is serving the
21principal at this time, an employe of the health care provider, other than a chaplain
22or a social worker, or an employe, other than a chaplain or a social worker, of an
23inpatient health care facility in which the declarant is a patient. I am not the
24principal's health care agent. To the best of my knowledge, I am not entitled to and
25do not have a claim on the principal's estate.
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1Witness No. 1:
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(print) Name.... Date....
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Signature....
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Witness No. 2:
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(print) Name.... Date....
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Signature....
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STATEMENT OF HEALTH CARE AGENT
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AND ALTERNATE HEALTH CARE AGENT
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I understand that.... (name of principal) has designated me to be his or her
12health care agent or alternate health care agent if he or she is ever found to have
13incapacity and unable to make health care decisions himself or herself. .... (name
14of principal) has discussed his or her desires regarding health care decisions with me.
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Agent's signature....
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Address....
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Alternate's signature....
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Address....
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Failure to execute a power of attorney for health care document under chapter
20155 of the Wisconsin Statutes creates no presumption about the intent of any
21individual 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
23of the Wisconsin Statutes.
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24ANATOMICAL GIFTS (OPTIONAL)
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25Upon my death:
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1.... I wish to donate only the following organs or parts: .... (specify the organs
2or parts).
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3.... I wish to donate any needed organ or part.
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4.... I wish to donate my body for anatomical study if needed.
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5.... I refuse to make an anatomical gift.
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6Failing to check any of the lines immediately above creates no presumption
7about my desire to make or refuse to make an anatomical gift.
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8Signature.... Date....
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9Section
3. 157.06 (2) (f) 1m. of the statutes is created to read:
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157.06
(2) (f) 1m. Signing a new document of gift. Signing a new document of
11gift revokes any previously signed document of gift.
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12Section
4. 157.06 (2) (f) 6. of the statutes is created to read:
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157.06
(2) (f) 6. Revoking the provision of a power of attorney for health care
14instrument that makes an anatomical gift or revoking that power of attorney for
15health care instrument.
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16Section
5. 157.06 (3) (a) 7. of the statutes is created to read:
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157.06
(3) (a) 7. A health care agent, as defined in s. 155.01 (4), for the decedent
18at the time of death.
