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INSPECTION AND DISCLOSURE OF
14
INFORMATION RELATING TO MY PHYSICAL
15
OR MENTAL HEALTH
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Subject to any limitations in this document, my health care agent has the
17authority to do all of the following:
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(a) Request, review and receive any information, oral or written, regarding my
19physical 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
21this 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 of attorney for health care)
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1Signature.... Date....
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(The signing of this document by the principal revokes all previous powers of
3attorney 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
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.
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Witness No. 1:
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(print) Name.... Date....
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Address....
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Signature....
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Witness No. 2:
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(print) Name.... Date....
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Address....
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Signature....
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STATEMENT OF HEALTH CARE AGENT AND
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ALTERNATE HEALTH CARE AGENT
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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.
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Agent's signature....
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Alternate's signature....
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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.
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This power of attorney for health care is executed as provided in chapter 155
13of 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
17parts).
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.... I wish to donate any needed organ or part.
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.... I wish to donate my body for anatomical study if needed.
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.... 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.)
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Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
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Signature.... Date....
SB377, s. 54
1Section
54. 632.88 (1) (a) of the statutes is amended to read:
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632.88
(1) (a) Incapable of self-sustaining employment because of
mental
3retardation intellectual disability or physical handicap; and
