AB915,7,2121 LIMITATIONS ON
AB915,7,2222 MENTAL HEALTH TREATMENT
AB915,8,223 My health care agent may not admit or commit me on an inpatient basis to an
24institution for mental diseases, an intermediate care facility for the mentally
25retarded, a state treatment facility or a treatment facility. My health care agent may

1not consent to experimental mental health research or psychosurgery,
2electroconvulsive treatment or drastic mental health treatment procedures for me.
AB915,8,43 ADMISSION TO NURSING HOMES
4 OR COMMUNITY-BASED RESIDENTIAL FACILITIES
AB915,8,65 My health care agent may admit me to a nursing home or community-based
6residential facility for short-term stays for recuperative care or respite care.
AB915,8,97 If I have checked "Yes" to the following, my health care agent may admit me for
8a purpose other than recuperative care or respite care, but if I have checked "No" to
9the following, my health care agent may not so admit me:
AB915,8,1010 1. A nursing home — Yes.... No....
AB915,8,1111 2. A community-based residential facility — Yes.... No....
AB915,8,1312 If I have not checked either "Yes" or "No" immediately above, my health care
13agent may admit me only for short-term stays for recuperative care or respite care.
AB915,8,1414 PROVISION OF A FEEDING TUBE
AB915,8,1915 If I have checked "Yes" to the following, my health care agent may have a
16feeding tube withheld or withdrawn from me, unless my physician has advised that,
17in his or her professional judgment, this will cause me pain or will reduce my comfort.
18If I have checked "No" to the following, my health care agent may not have a feeding
19tube withheld or withdrawn from me.
AB915,8,2220 My health care agent may not have orally ingested nutrition or hydration
21withheld or withdrawn from me unless provision of the nutrition or hydration is
22medically contraindicated.
AB915,8,2323 Withhold or withdraw a feeding tube — Yes.... No....
AB915,8,2524 If I have not checked either "Yes" or "No" immediately above, my health care
25agent may not have a feeding tube withdrawn from me.
AB915,9,1
1HEALTH CARE DECISIONS
AB915,9,22 FOR PREGNANT WOMEN
AB915,9,63 If I have checked "Yes" to the following, my health care agent may make health
4care decisions for me even if my agent knows I am pregnant. If I have checked "No"
5to the following, my health care agent may not make health care decisions for me if
6my health care agent knows I am pregnant.
AB915,9,77 Health care decision if I am pregnant — Yes.... No....
AB915,9,108 If I have not checked either "Yes" or "No" immediately above, my health care
9agent may not make health care decisions for me if my health care agent knows I am
10pregnant.
AB915,9,1111 STATEMENT OF DESIRES, SPECIAL
AB915,9,1212 PROVISIONS OR LIMITATIONS
AB915,9,1613 In exercising authority under this document, my health care agent shall act
14consistently with my following stated desires, if any, and is subject to any special
15provisions or limitations that I specify. The following are specific desires, provisions
16or limitations that I wish to state (add more items if needed):
AB915,9,1717 1) -
AB915,9,1818 2) -
AB915,9,1919 3) -
AB915,9,2020 INSPECTION AND DISCLOSURE OF INFORMATION
AB915,9,2121 RELATING TO MY PHYSICAL OR MENTAL HEALTH
AB915,9,2322 Subject to any limitations in this document, my health care agent has the
23authority to do all of the following:
AB915,9,2524 (a) Request, review and receive any information, oral or written, regarding my
25physical or mental health, including medical and hospital records.
AB915,10,2
1(b) Execute on my behalf any documents that may be required in order to obtain
2this information.
AB915,10,33 (c) Consent to the disclosure of this information.
AB915,10,44 (The principal and the witnesses all must sign the document at the same time.)
AB915,10,55 SIGNATURE OF PRINCIPAL
AB915,10,66 (person creating the power
AB915,10,77 of attorney for health care)
AB915,10,88 Signature.... Date....
AB915,10,109 (The signing of this document by the principal revokes all previous powers of
10attorney for health care documents.)
AB915,10,1111 STATEMENT OF WITNESSES
AB915,10,2112 I know the principal personally and I believe him or her to be of sound mind and
13at least 18 years of age. I believe that his or her execution of this power of attorney
14for health care is voluntary. I am at least 18 years of age, am not related to the
15principal by blood, marriage or adoption and am not directly financially responsible
16for the principal's health care. I am not a health care provider who is serving the
17principal at this time, an employe of the health care provider, other than a chaplain
18or a social worker, or an employe, other than a chaplain or a social worker, of an
19inpatient health care facility in which the declarant is a patient. I am not the
20principal's health care agent. To the best of my knowledge, I am not entitled to and
21do not have a claim on the principal's estate.
AB915,10,2222 Witness No. 1:
AB915,10,2323 (print) Name.... Date....
AB915,10,2424 Address....
AB915,10,2525 Signature....
AB915,11,1
1Witness No. 2:
AB915,11,22 (print) Name.... Date....
AB915,11,33 Address....
AB915,11,44 Signature....
AB915,11,55 STATEMENT OF HEALTH CARE AGENT
AB915,11,66 AND ALTERNATE HEALTH CARE AGENT
AB915,11,107 I understand that.... (name of principal) has designated me to be his or her
8health care agent or alternate health care agent if he or she is ever found to have
9incapacity and unable to make health care decisions himself or herself. .... (name of
10principal) has discussed his or her desires regarding health care decisions with me.
AB915,11,1111 Agent's signature....
AB915,11,1212 Address....
AB915,11,1313 Alternate's signature....
AB915,11,1414 Address....
AB915,11,1715 Failure to execute a power of attorney for health care document under chapter
16155 of the Wisconsin Statutes creates no presumption about the intent of any
17individual with regard to his or her health care decisions.
AB915,11,1918 This power of attorney for health care is executed as provided in chapter 155
19of the Wisconsin Statutes.
AB915,11,2020 ANATOMICAL GIFTS (optional)
AB915,11,2121 Upon my death:
AB915,11,2322 .... I wish to donate only the following organs or parts: .... (specify the organs or
23parts).
AB915,11,2424 .... I wish to donate any needed organ or part.
AB915,12,4
1.... I wish to donate my body for anatomical study if needed. (Since many
2institutions have certain conditions that must be met before receiving donation of a
3body, I will attempt to contact the institution to which the donation is intended to be
4made.)
AB915,12,75 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
6I have made to make an anatomical gift to a designated donee, I will attempt to notify
7the donee to which or to whom I agreed to donate.)
AB915,12,98 Failing to check any of the lines immediately above creates no presumption
9about my desire to make or refuse to make an anatomical gift.
AB915,12,1010 Signature.... Date....
AB915, s. 7 11Section 7. 155.30 (3m) of the statutes is created to read:
AB915,12,1412 155.30 (3m) The department may modify the form specified in sub. (3) to
13include, for the purposes of making an anatomical gift, the toll-free telephone
14number of the Wisconsin donor registry under s. 157.06 (10r).
AB915, s. 8 15Section 8. 157.06 (1) (c) 2. of the statutes is renumbered 157.06 (1) (c) and
16amended to read:
AB915,12,2017 157.06 (1) (c) "Document of gift" means a card, a statement attached to or
18imprinted on a license under s. 343.175 (2) or on an identification card under s.
19343.50 (3), a will, an enrollment form signed as specified in sub. (10r) (b) or another
20writing used to make an anatomical gift.
AB915, s. 9 21Section 9. 157.06 (1) (em) of the statutes is created to read:
AB915,12,2322 157.06 (1) (em) "Eye bank" means a repository for donated human eyes or
23portions of eyes destined for ocular transplant surgery and research.
AB915, s. 10 24Section 10. 157.06 (1) (km) of the statutes is created to read:
AB915,12,2525 157.06 (1) (km) "Tissue bank" means a repository for donated tissue and bone.
AB915, s. 11
1Section 11. 157.06 (2) (b) of the statutes is amended to read:
AB915,13,72 157.06 (2) (b) An anatomical gift under par. (a) may be made only by a document
3of gift signed and dated by the donor. If the donor cannot so sign and date, the
4document of gift shall be signed and dated by another individual and by 2 witnesses,
5all of whom have signed and dated at the direction and in the presence of the donor
6and of each other, and the document of gift shall state that it has been so signed and
7dated
.
AB915, s. 12 8Section 12. 157.06 (2) (f) 1. of the statutes is amended to read:
AB915,13,99 157.06 (2) (f) 1. Signing and dating a statement of amendment or revocation.
AB915, s. 13 10Section 13. 157.06 (2) (f) 1m. of the statutes is amended to read:
AB915,13,1311 157.06 (2) (f) 1m. Signing and dating a new document of gift. Signing and
12dating
a new document of gift revokes any previously signed and dated document of
13gift.
AB915, s. 14 14Section 14. 157.06 (2) (f) 4. of the statutes is amended to read:
AB915,13,1615 157.06 (2) (f) 4. Delivering a signed and dated statement of amendment or
16revocation to a specified donee to whom a document of gift had been delivered.
AB915, s. 15 17Section 15. 157.06 (2) (f) 5. b. of the statutes is renumbered 157.06 (2) (f) 5.
18and amended to read:
AB915,13,2119 157.06 (2) (f) 5. Crossing out or amending and dating the donor authorization
20or refusal in the space provided on his or her license as prescribed in s. 343.175 (2)
21or identification card as prescribed in s. 343.50 (3).
AB915, s. 16 22Section 16. 157.06 (2) (i) 1. of the statutes is amended to read:
AB915,13,2423 157.06 (2) (i) 1. Making a writing of refusal that is signed and dated in the same
24manner as is required for a document of gift.
AB915, s. 17 25Section 17. 157.06 (2) (i) 2. b. of the statutes is amended to read:
AB915,14,3
1157.06 (2) (i) 2. b. Attaching Dating and attaching a statement of refusal to or
2imprinting a statement of refusal on his or her license under s. 343.175 (2) or
3identification card under s. 343.50 (3).
AB915, s. 18 4Section 18. 157.06 (2) (i) 3. of the statutes is amended to read:
AB915,14,85 157.06 (2) (i) 3. Making and dating any other writing that is used to identify
6the individual as refusing to make an anatomical gift. During the individual's
7terminal illness or injury, he or she may make the refusal by an oral statement or
8other form of communication to another.
AB915, s. 19 9Section 19. 157.06 (2) (L) of the statutes is created to read:
Loading...
Loading...