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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