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(print) Name.... Date....
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Address....
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Signature....
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1Witness 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
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.
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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
16155 of the Wisconsin Statutes creates no presumption about the intent of any
17individual 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
19of 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
23parts).
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.... I wish to donate any needed organ or part.
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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.)
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.... 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.)
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Failing to check any of the lines immediately above creates no presumption
9about my desire to make or refuse to make an anatomical gift.
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Signature.... Date....
AB915, s. 7
11Section
7. 155.30 (3m) of the statutes is created to read:
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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:
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157.06
(1) (em) "Eye bank" means a repository for donated human eyes or
23portions of eyes destined for ocular transplant surgery and research.
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24Section
10. 157.06 (1) (km) of the statutes is created to read:
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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:
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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:
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157.06
(2) (f) 1. Signing
and dating a statement of amendment or revocation.
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10Section
13. 157.06 (2) (f) 1m. of the statutes is amended to read:
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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.
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14Section
14. 157.06 (2) (f) 4. of the statutes is amended to read:
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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.
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17Section
15. 157.06 (2) (f) 5. b. of the statutes is renumbered 157.06 (2) (f) 5.
18and amended to read:
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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:
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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.
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25Section
17. 157.06 (2) (i) 2. b. of the statutes is amended to read:
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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:
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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:
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157.06
(2) (L) Notwithstanding the requirements for dating documents under
11pars. (b), (f) 1., 1m. 4. and 5. and (i) 1., 2. b. and 3. and s. 343.175 (2) (ar) and (b), and
12except as provided in ss. 155.10 (1) (b) and 155.40 (1) (b), all of the following apply:
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1. The existence of a document of gift in undated form does not invalidate the
14document of gift.
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2. The existence of a written but undated amendment to a document of gift does
16not invalidate the amendment.
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3. The existence of a written but undated revocation of an anatomical gift does
18not invalidate the revocation.
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4. The existence of a written but undated refusal to make an anatomical gift
20does not invalidate the refusal.
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5. The existence of a written but undated revocation of a refusal to make an
22anatomical gift does not invalidate the revocation of the refusal.
AB915, s. 20
23Section
20. 157.06 (10m) of the statutes is created to read:
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157.06
(10m) Donor registry board. (a) The donor registry board shall do all
25of the following:
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11. Review requests for proposals and, from the appropriation under s. 20.435
2(1) (bm), award one or more contracts to establish, operate and maintain the
3Wisconsin donor registry. The board shall consult with the department in preparing
4requests for proposals under this subdivision. A contract under this subdivision
5shall specify that the awardee shall, at the end of the contract term or if the contract
6is otherwise terminated, relinquish to the board the names of enrollees and other
7information in the registry and any rights to a toll-free telephone number for the
8registry.
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2. Direct and monitor or, from the appropriation under s. 20.435 (1) (bm), award
10a contract for the monitoring of the operation of and services provided by the
11Wisconsin donor registry.
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3. Promulgate rules that ensure the confidentiality of enrollees of the
13Wisconsin donor registry.
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4. Study the effectiveness of the Wisconsin donor registry and, by March 1,
152003, report the study results to the legislature under s. 13.172 (2) and to the
16governor.
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(b) The department of health and family services shall provide technical
18support to the donor registry board.
AB915, s. 21
19Section
21. 157.06 (10m) (a) 1. of the statutes, as created by 1999 Wisconsin
20Act .... (this act), is amended to read:
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157.06
(10m) (a) 1. Review requests for proposals and, from the appropriation
22under s. 20.435 (1) (bm), award one or more contracts to
establish, operate and
23maintain the Wisconsin donor registry. The board shall consult with the department
24in preparing requests for proposals under this subdivision. A contract under this
25subdivision shall specify that the awardee shall, at the end of the contract term or
1if the contract is otherwise terminated, relinquish to the board the names of enrollees
2and other information in the registry and any rights to a toll-free telephone number
3for the registry.
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4Section
22. 157.06 (10r) of the statutes is created to read:
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157.06
(10r) Wisconsin donor registry. (a) Under a contract that is awarded
6under sub. (10m) (a) 1., an entity shall establish, operate and maintain an organ and
7tissue donor registry, to be known as the "Wisconsin donor registry", that includes
8the names of and pertinent information concerning persons who are enrolled to
9provide anatomical gifts. The entity may release information from the registry only
10to organ procurement organizations, eye banks, tissue banks, the donor registry
11board and its staff and any successor contractor. Information in the registry is not
12available for inspection or copying under s. 19.35 (1).
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(b) An individual who desires to make an anatomical gift and to be enrolled in
14the Wisconsin donor registry shall sign an enrollment form and return the form to
15the registry or to the department of transportation under s. 343.14 (6) (b) or 343.50
16(4m) (c). The enrollment form may be designed by the entity that operates and
17maintains the registry, but no form may conflict with the requirements of this
18section.
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(c) The entity that operates and maintains the Wisconsin donor registry shall
20operate a toll-free telephone number and may maintain an Internet Web site, to
21provide information about making an anatomical gift and about enrollment in and
22disenrollment from the registry. Any computer technology developed by the entity
23under this paragraph is the property of the donor registry board.
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1(d) No organ procurement organization, tissue bank or eye bank may be
2required to contribute directly money or any other thing of value to provide payment
3for operation of the Wisconsin donor registry.
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4Section
23. 157.06 (10r) (a) of the statutes, as created by 1999 Wisconsin Act
5.... (this act), is amended to read:
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157.06
(10r) (a) Under a contract that is awarded under sub. (10m) (a) 1., an
7entity shall
establish, operate and maintain an organ and tissue donor registry, to
8be known as the "Wisconsin donor registry", that includes the names of and pertinent
9information concerning persons who are enrolled to provide anatomical gifts. The
10entity may release information from the registry only to organ procurement
11organizations, eye banks, tissue banks, the donor registry board and its staff and any
12successor contractor. Information in the registry is not available for inspection or
13copying under s. 19.35 (1).
AB915, s. 24
14Section
24. 343.14 (2) (g) 2m. of the statutes is created to read:
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343.14
(2) (g) 2m. The name and address of the applicant will be forwarded by
16the department to the Wisconsin donor registry under s. 157.06 (10r) (a) if the
17response to the question under this paragraph is affirmative.
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18Section
25. 343.14 (6) of the statutes is renumbered 343.14 (6) (a).
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19Section
26. 343.14 (6) (b) of the statutes is created to read:
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343.14
(6) (b) Notwithstanding par. (a), the department shall disseminate to
21applicants the enrollment form specified under s. 157.06 (10r) (b). An applicant may
22make an anatomical gift and be enrolled in the Wisconsin donor registry under s.
23157.06 (10r) (a) by signing the enrollment form and returning it to the registry. The
24department shall inform applicants that enrollment in the Wisconsin donor registry
25is not required to make an anatomical gift.
AB915, s. 27
1Section
27. 343.17 (3) (b) of the statutes is amended to read:
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343.17
(3) (b) The reverse side of the license shall contain an explanation of any
3restriction codes or endorsement abbreviations used on the front of the license, in
4sufficient detail to identify the nature of the restrictions or endorsements to a law
5enforcement officer of this state or another jurisdiction. Except for a commercial
6driver license or a license labeled "CDL-Occupational" as described in s. 343.03 (3)
7(b) and (e), a part of the reverse side of each license shall be printed to serve as a
8document of gift under s. 157.06 (2) (b) and (c) or a document of refusal to make an
9anatomical gift under s. 157.06 (2) (i)
, shall include the words "Wisconsin donor
10registry" and the toll-free telephone number that can be used by persons desiring to
11obtain the information specified under s. 157.06 (10r) (c), and shall be titled "ORGAN
12AND TISSUE DONATION STATEMENT".
AB915, s. 28
13Section
28. 343.175 (1) of the statutes is amended to read:
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343.175
(1) Department to solicit and record information. As part of every
15application for an original, duplicate, reinstated, reissued or renewal license or
16endorsement, the department shall inquire whether the applicant desires to be an
17organ donor. The department shall record the organ donor response in its file of the
18person.
At not less than 3-month intervals, the department shall compile a list of
19the names and addresses of persons whose response to the inquiry under this
20subsection is affirmative and forward it to the Wisconsin donor registry under s.
21157.06 (10r) (a).
AB915, s. 29
22Section
29. 343.175 (2) (a) of the statutes is amended to read:
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343.175
(2) (a) Except as provided in par. (ag), a part of the reverse side of each
24license shall be printed to serve as a document of gift under s. 157.06 (2) (b) and (c)
25or a document of refusal to make an anatomical gift under s. 157.06 (2) (i)
, shall
1include the words "Wisconsin donor registry" and the toll-free telephone number
2that can be used by persons desiring to obtain the information specified under s.
3157.06 (10r) (c), and shall be titled "ORGAN AND TISSUE DONATION
4STATEMENT".
AB915, s. 30
5Section
30. 343.175 (2) (ag) of the statutes is amended to read:
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343.175
(2) (ag) The department shall print a separate document to be issued
7to all persons issued a commercial driver license or a license labeled
8"CDL-Occupational" as described in s. 343.03 (3) (b) and (e) and make provisions so
9that the document may be attached to the reverse side of the license document along
10one edge. This document shall serve as a document of gift under s. 157.06 (2) (b) and
11(c) or a document of refusal to make an anatomical gift under s. 157.06 (2) (i)
, shall
12include the words "Wisconsin donor registry" and the toll-free telephone number
13that can be used by persons desiring to obtain the information specified under s.
14157.06 (10r) (c), and shall be titled "ORGAN AND TISSUE DONATION
15STATEMENT".
AB915, s. 31
16Section
31. 343.175 (2) (ar) of the statutes is amended to read:
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343.175
(2) (ar) If the person desires to be an organ donor, he or she may so
18indicate in the space provided on the license. The donor may supply information in
19the space provided on the license, including the specific body parts or organs to be
20donated, the name of the donee, the purpose for which the gift is made and the
21physician whom the donor wishes to carry out the appropriate procedures. The
22anatomical gift described on the license shall be signed
and dated by the licensee.
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23Section
32. 343.175 (2) (b) of the statutes is amended to read:
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343.175
(2) (b) The licensee may revoke or amend his or her gift by crossing out
25the donor authorization in the space provided on the license
and dating it, or as
1otherwise prescribed in s. 157.06. The licensee may refuse to make an anatomical
2gift by so indicating in the space provided on the license
and dating it, or as otherwise
3prescribed in s. 157.06.
AB915, s. 33
4Section
33. 343.20 (2m) of the statutes is amended to read: