SB548,23,169 I,.... (print name, address and date of birth), being of sound mind, intend by this
10document to create a power of attorney for health care. My executing this power of
11attorney for health care is voluntary. Despite the creation of this power of attorney
12for health care, I expect to be fully informed about and allowed to participate in any
13health care decision for me, to the extent that I am able. For the purposes of this
14document, "health care decision" means an informed decision to accept, maintain,
15discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
16or treat my physical or mental condition.
SB548,23,1817 In addition, I may, by this document, specify my wishes with respect to making
18an anatomical gift upon my death.
SB548,23,1919 DESIGNATION OF HEALTH CARE AGENT
SB548,24,920 If I am no longer able to make health care decisions for myself, due to my
21incapacity, I hereby designate.... (print name, address and telephone number) to be
22my health care agent for the purpose of making health care decisions on my behalf.
23If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
24address and telephone number) to be my alternate health care agent for the purpose
25of making health care decisions on my behalf. Neither my health care agent nor my

1alternate health care agent whom I have designated is my health care provider, an
2employee of my health care provider, an employee of a health care facility in which
3I am a patient or a spouse of any of those persons, unless he or she is also my relative.
4For purposes of this document, "incapacity" exists if 2 physicians or a physician and
5a psychologist who have personally examined me sign a statement that specifically
6expresses their opinion that I have a condition that means that I am unable to receive
7and evaluate information effectively or to communicate decisions to such an extent
8that I lack the capacity to manage my health care decisions. A copy of that statement
9must be attached to this document.
SB548,24,1010 GENERAL STATEMENT OF
SB548,24,1111 AUTHORITY GRANTED
SB548,24,1812 Unless I have specified otherwise in this document, if I ever have incapacity I
13instruct my health care provider to obtain the health care decision of my health care
14agent, if I need treatment, for all of my health care and treatment. I have discussed
15my desires thoroughly with my health care agent and believe that he or she
16understands my philosophy regarding the health care decisions I would make if I
17were able. I desire that my wishes be carried out through the authority given to my
18health care agent under this document.
SB548,25,219 If I am unable, due to my incapacity, to make a health care decision, my health
20care agent is instructed to make the health care decision for me, but my health care
21agent should try to discuss with me any specific proposed health care if I am able to
22communicate in any manner, including by blinking my eyes. If this communication
23cannot be made, my health care agent shall base his or her decision on any health
24care choices that I have expressed prior to the time of the decision. If I have not
25expressed a health care choice about the health care in question and communication

1cannot be made, my health care agent shall base his or her health care decision on
2what he or she believes to be in my best interest.
SB548,25,33 LIMITATIONS ON
SB548,25,44 MENTAL HEALTH TREATMENT
SB548,25,105 My health care agent may not admit or commit me on an inpatient basis to an
6institution for mental diseases, an intermediate care facility for the mentally
7retarded
persons with mental retardation, a state treatment facility or a treatment
8facility. My health care agent may not consent to experimental mental health
9research or psychosurgery, electroconvulsive treatment or drastic mental health
10treatment procedures for me.
SB548,25,1111 ADMISSION TO NURSING HOMES
SB548,25,1212 OR COMMUNITY-BASED RESIDENTIAL FACILITIES
SB548,25,1413 My health care agent may admit me to a nursing home or community-based
14residential facility for short-term stays for recuperative care or respite care.
SB548,25,1715 If I have checked "Yes" to the following, my health care agent may admit me for
16a purpose other than recuperative care or respite care, but if I have checked "No" to
17the following, my health care agent may not so admit me:
SB548,25,1818 1. A nursing home — Yes.... No....
SB548,25,1919 2. A community-based residential facility — Yes.... No....
SB548,25,2120 If I have not checked either "Yes" or "No" immediately above, my health care
21agent may admit me only for short-term stays for recuperative care or respite care.
SB548,25,2222 PROVISION OF A FEEDING TUBE
SB548,26,223 If I have checked "Yes" to the following, my health care agent may have a
24feeding tube withheld or withdrawn from me, unless my physician has advised that,
25in his or her professional judgment, this will cause me pain or will reduce my comfort.

1If I have checked "No" to the following, my health care agent may not have a feeding
2tube withheld or withdrawn from me.
SB548,26,53 My health care agent may not have orally ingested nutrition or hydration
4withheld or withdrawn from me unless provision of the nutrition or hydration is
5medically contraindicated.
SB548,26,66 Withhold or withdraw a feeding tube — Yes.... No....
SB548,26,87 If I have not checked either "Yes" or "No" immediately above, my health care
8agent may not have a feeding tube withdrawn from me.
SB548,26,99 HEALTH CARE DECISIONS
SB548,26,1010 FOR PREGNANT WOMEN
SB548,26,1411 If I have checked "Yes" to the following, my health care agent may make health
12care decisions for me even if my agent knows I am pregnant. If I have checked "No"
13to the following, my health care agent may not make health care decisions for me if
14my health care agent knows I am pregnant.
SB548,26,1515 Health care decision if I am pregnant — Yes.... No....
SB548,26,1816 If I have not checked either "Yes" or "No" immediately above, my health care
17agent may not make health care decisions for me if my health care agent knows I am
18pregnant.
SB548,26,1919 STATEMENT OF DESIRES, SPECIAL
SB548,26,2020 PROVISIONS OR LIMITATIONS
SB548,26,2421 In exercising authority under this document, my health care agent shall act
22consistently with my following stated desires, if any, and is subject to any special
23provisions or limitations that I specify. The following are specific desires, provisions
24or limitations that I wish to state (add more items if needed):
SB548,26,2525 1) -
SB548,27,1
12) -
SB548,27,22 3) -
SB548,27,33 INSPECTION AND DISCLOSURE OF INFORMATION
SB548,27,44 RELATING TO MY PHYSICAL OR MENTAL HEALTH
SB548,27,65 Subject to any limitations in this document, my health care agent has the
6authority to do all of the following:
SB548,27,87 (a) Request, review and receive any information, oral or written, regarding my
8physical or mental health, including medical and hospital records.
SB548,27,109 (b) Execute on my behalf any documents that may be required in order to obtain
10this information.
SB548,27,1111 (c) Consent to the disclosure of this information.
SB548,27,1212 (The principal and the witnesses all must sign the document at the same time.)
SB548,27,1313 SIGNATURE OF PRINCIPAL
SB548,27,1414 (person creating the power of attorney for health care)
SB548,27,1515 Signature....                              Date....
SB548,27,1716 (The signing of this document by the principal revokes all previous powers of
17attorney for health care documents.)
SB548,27,1818 STATEMENT OF WITNESSES
SB548,28,319 I know the principal personally and I believe him or her to be of sound mind and
20at least 18 years of age. I believe that his or her execution of this power of attorney
21for health care is voluntary. I am at least 18 years of age, am not related to the
22principal by blood, marriage or adoption and am not directly financially responsible
23for the principal's health care. I am not a health care provider who is serving the
24principal at this time, an employee of the health care provider, other than a chaplain
25or a social worker, or an employee, other than a chaplain or a social worker, of an

1inpatient health care facility in which the declarant is a patient. I am not the
2principal's health care agent. To the best of my knowledge, I am not entitled to and
3do not have a claim on the principal's estate.
SB548,28,44 Witness No. 1:
SB548,28,55 (print) Name....                               Date....
SB548,28,66 Address....
SB548,28,77 Signature....
SB548,28,88 Witness No. 2:
SB548,28,99 (print) Name....                               Date....
SB548,28,1010 Address....
SB548,28,1111 Signature....
SB548,28,1212 STATEMENT OF HEALTH CARE AGENT
SB548,28,1313 AND ALTERNATE HEALTH CARE AGENT
SB548,28,1714 I understand that.... (name of principal) has designated me to be his or her
15health care agent or alternate health care agent if he or she is ever found to have
16incapacity and unable to make health care decisions himself or herself. .... (name of
17principal) has discussed his or her desires regarding health care decisions with me.
SB548,28,1818 Agent's signature....
SB548,28,1919 Address....
SB548,28,2020 Alternate's signature....
SB548,28,2121 Address....
SB548,28,2422 Failure to execute a power of attorney for health care document under chapter
23155 of the Wisconsin Statutes creates no presumption about the intent of any
24individual with regard to his or her health care decisions.
SB548,29,2
1This power of attorney for health care is executed as provided in chapter 155
2of the Wisconsin Statutes.
SB548,29,33 ANATOMICAL GIFTS (optional)
SB548,29,44 Upon my death:
SB548,29,65 .... I wish to donate only the following organs or parts: .... (specify the organs or
6parts).
SB548,29,77 .... I wish to donate any needed organ or part.
SB548,29,88 .... I wish to donate my body for anatomical study if needed.
SB548,29,119 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
10I have made to make an anatomical gift to a designated donee, I will attempt to notify
11the donee to which or to whom I agreed to donate.)
SB548,29,1312 Failing to check any of the lines immediately above creates no presumption
13about my desire to make or refuse to make an anatomical gift.
SB548,29,1414 Signature....                                   Date....
SB548, s. 79 15Section 79. 250.042 (4) (a) 3. of the statutes is amended to read:
SB548,29,2316 250.042 (4) (a) 3. "Health care provider" means an individual who, at any time
17within 10 years before a state of emergency is declared under s. 166.03 (1) (b) 1. or
18166.23, has met requirements for a nurse's assistant nurse aide under s. 146.40 (2)
19(a), (b), (bm), (c), (e), (em), (f), or (g), has been licensed as a physician, a physician
20assistant, or a podiatrist under ch. 448, licensed as a registered nurse, licensed
21practical nurse, or nurse-midwife under ch. 441, licensed as a dentist under ch. 447,
22licensed as a pharmacist under ch. 450, licensed as a veterinarian under ch. 453, or
23has been certified as a respiratory care practitioner under ch. 448.
SB548, s. 80 24Section 80. 250.042 (4) (b) of the statutes is amended to read:
SB548,30,14
1250.042 (4) (b) A behavioral health provider, health care provider, pupil
2services provider, or substance abuse prevention provider who, during a state of
3emergency declared under s. 166.03 (1) (b) 1. or 166.23, provides behavioral health
4services, health care services, pupil services, or substance abuse prevention services
5for which the behavioral health provider, health care provider, pupil services
6provider, or substance abuse prevention provider has been licensed or certified or, as
7a nurse's assistant nurse aide, has met requirements under s. 146.40, is, for the
8provision of these services a state agent of the department for purposes of ss. 165.25
9(6), 893.82, and 895.46 and is an employee of the state for purposes of worker's
10compensation benefits. The behavioral health services, health care services, pupil
11services, or substance abuse prevention services shall be provided on behalf of a
12health care facility on a voluntary, unpaid basis, except that the behavioral health
13provider, health care provider, pupil services provider, or substance abuse
14prevention provider may accept reimbursement for travel, lodging, and meals.
SB548, s. 81 15Section 81. 250.042 (4) (c) 12. of the statutes is amended to read:
SB548,30,1816 250.042 (4) (c) 12. A nurse's assistant nurse aide whose name is listed under
17s. 146.40 (4g) (a) 2., 2005 stats., or a nurse aide whose name is listed under s. 146.40
18(4g) (a) 2
.
SB548, s. 82 19Section 82. 440.03 (3q) of the statutes is amended to read:
SB548,30,2220 440.03 (3q) Notwithstanding sub. (3m), the department of regulation and
21licensing shall investigate any report that it receives under s. 146.40 (4r) (am) 2. or
22(em).
SB548, s. 83 23Section 83. 632.895 (1) (b) 2. of the statutes is amended to read:
SB548,31,224 632.895 (1) (b) 2. Part-time or intermittent home health aide services which
25that are medically necessary as part of the home care plan, under the supervision of

1a registered nurse or medical social worker, which consist solely of caring for the
2patient.
SB548, s. 84 3Section 84. 632.895 (2) (d) of the statutes is amended to read:
SB548,31,94 632.895 (2) (d) Each visit by a person providing services under a home care plan
5or evaluating the need for or developing a plan shall be considered as one home care
6visit. The policy may contain a limit on the number of home care visits, but not less
7than 40 visits in any 12-month period, for each person covered under the policy. Up
8to 4 consecutive hours in a 24-hour period of home health aide service shall be
9considered as one home care visit.
SB548, s. 85 10Section 85. Effective date.
SB548,31,1111 (1) This act takes effect on January 1, 2009.
SB548,31,1212 (End)
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