SB377,19,184 If I am no longer able to make health care decisions for myself, due to my
5incapacity, I hereby designate.... (print name, address and telephone number) to be
6my health care agent for the purpose of making health care decisions on my behalf.
7If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
8address and telephone number) to be my alternate health care agent for the purpose
9of making health care decisions on my behalf. Neither my health care agent nor my
10alternate health care agent whom I have designated is my health care provider, an
11employee of my health care provider, an employee of a health care facility in which
12I am a patient or a spouse of any of those persons, unless he or she is also my relative.
13For purposes of this document, "incapacity" exists if 2 physicians or a physician and
14a psychologist who have personally examined me sign a statement that specifically
15expresses their opinion that I have a condition that means that I am unable to receive
16and evaluate information effectively or to communicate decisions to such an extent
17that I lack the capacity to manage my health care decisions. A copy of that statement
18must be attached to this document.
SB377,19,1919 GENERAL STATEMENT OF AUTHORITY GRANTED
SB377,20,220 Unless I have specified otherwise in this document, if I ever have incapacity I
21instruct my health care provider to obtain the health care decision of my health care
22agent, if I need treatment, for all of my health care and treatment. I have discussed
23my desires thoroughly with my health care agent and believe that he or she
24understands my philosophy regarding the health care decisions I would make if I

1were able. I desire that my wishes be carried out through the authority given to my
2health care agent under this document.
SB377,20,113 If I am unable, due to my incapacity, to make a health care decision, my health
4care agent is instructed to make the health care decision for me, but my health care
5agent should try to discuss with me any specific proposed health care if I am able to
6communicate in any manner, including by blinking my eyes. If this communication
7cannot be made, my health care agent shall base his or her decision on any health
8care choices that I have expressed prior to the time of the decision. If I have not
9expressed a health care choice about the health care in question and communication
10cannot be made, my health care agent shall base his or her health care decision on
11what he or she believes to be in my best interest.
SB377,20,1212 LIMITATIONS ON MENTAL HEALTH TREATMENT
SB377,20,1813 My health care agent may not admit or commit me on an inpatient basis to an
14institution for mental diseases, an intermediate care facility for persons with mental
15retardation
an intellectual disability, a state treatment facility or a treatment
16facility. My health care agent may not consent to experimental mental health
17research or psychosurgery, electroconvulsive treatment or drastic mental health
18treatment procedures for me.
SB377,20,2019 ADMISSION TO NURSING HOMES OR
20 COMMUNITY-BASED RESIDENTIAL FACILITIES
SB377,20,2221 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.
SB377,20,2523 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:
SB377,21,1
11. A nursing home — Yes.... No....
SB377,21,22 2. A community-based residential facility — Yes.... No....
SB377,21,43 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.
SB377,21,55 PROVISION OF A FEEDING TUBE
SB377,21,106 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.
SB377,21,1311 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.
SB377,21,1414 Withhold or withdraw a feeding tube — Yes.... No....
SB377,21,1615 If I have not checked either "Yes" or "No" immediately above, my health care
16agent may not have a feeding tube withdrawn from me.
SB377,21,1817 HEALTH CARE DECISIONS FOR
18 PREGNANT WOMEN
SB377,21,2219 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.
SB377,21,2323 Health care decision if I am pregnant — Yes.... No....
SB377,22,3
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.
SB377,22,54 STATEMENT OF DESIRES,
5 SPECIAL PROVISIONS OR LIMITATIONS
SB377,22,96 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):
SB377,22,1010 1) -
SB377,22,1111 2) -
SB377,22,1212 3) -
SB377,22,1513 INSPECTION AND DISCLOSURE OF
14 INFORMATION RELATING TO MY PHYSICAL
15 OR MENTAL HEALTH
SB377,22,1716 Subject to any limitations in this document, my health care agent has the
17authority to do all of the following:
SB377,22,1918 (a) Request, review and receive any information, oral or written, regarding my
19physical or mental health, including medical and hospital records.
SB377,22,2120 (b) Execute on my behalf any documents that may be required in order to obtain
21this information.
SB377,22,2222 (c) Consent to the disclosure of this information.
SB377,22,2323 (The principal and the witnesses all must sign the document at the same time.)
SB377,22,2424 SIGNATURE OF PRINCIPAL
SB377,22,2525 (person creating the power of attorney for health care)
SB377,23,1
1Signature....  Date....
SB377,23,32 (The signing of this document by the principal revokes all previous powers of
3attorney for health care documents.)
SB377,23,44 STATEMENT OF WITNESSES
SB377,23,155 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.
SB377,23,1616 Witness No. 1:
SB377,23,1717 (print) Name.... Date....
SB377,23,1818 Address....
SB377,23,1919 Signature....
SB377,23,2020 Witness No. 2:
SB377,23,2121 (print) Name.... Date....
SB377,23,2222 Address....
SB377,23,2323 Signature....
SB377,23,2524 STATEMENT OF HEALTH CARE AGENT AND
25 ALTERNATE HEALTH CARE AGENT
SB377,24,4
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.
SB377,24,55 Agent's signature....
SB377,24,66 Address....
SB377,24,77 Alternate's signature....
SB377,24,88 Address....
SB377,24,119 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.
SB377,24,1312 This power of attorney for health care is executed as provided in chapter 155
13of the Wisconsin Statutes.
SB377,24,1414 ANATOMICAL GIFTS (optional)
SB377,24,1515 Upon my death:
SB377,24,1716 .... I wish to donate only the following organs or parts: .... (specify the organs or
17parts).
SB377,24,1818 .... I wish to donate any needed organ or part.
SB377,24,1919 .... I wish to donate my body for anatomical study if needed.
SB377,24,2220 .... 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.)
SB377,24,2423 Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
SB377,24,2525 Signature....     Date....
SB377, s. 54
1Section 54. 632.88 (1) (a) of the statutes is amended to read:
SB377,25,32 632.88 (1) (a) Incapable of self-sustaining employment because of mental
3retardation
intellectual disability or physical handicap; and
SB377,25,44 (End)
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