AB695,22,1010
1. A nursing home — Yes.... No....
AB695,22,1111
2. A community-based residential facility — Yes.... No....
AB695,22,1312
If I have not checked either "Yes" or "No" immediately above, my health care
13agent may admit me only for short-term stays for recuperative care or respite care.
AB695,22,1414
PROVISION OF A FEEDING TUBE
AB695,22,1915
If I have checked "Yes" to the following, my health care agent may have a
16feeding tube withheld or withdrawn from me, unless my physician has advised that,
17in his or her professional judgment, this will cause me pain or will reduce my comfort.
18If I have checked "No" to the following, my health care agent may not have a feeding
19tube withheld or withdrawn from me.
AB695,22,2220
My health care agent may not have orally ingested nutrition or hydration
21withheld or withdrawn from me unless provision of the nutrition or hydration is
22medically contraindicated.
AB695,22,2323
Withhold or withdraw a feeding tube — Yes.... No....
AB695,22,2524
If I have not checked either "Yes" or "No" immediately above, my health care
25agent may not have a feeding tube withdrawn from me.
AB695,23,2
1HEALTH CARE DECISIONS FOR
2
PREGNANT WOMEN
AB695,23,63
If I have checked "Yes" to the following, my health care agent may make health
4care decisions for me even if my agent knows I am pregnant. If I have checked "No"
5to the following, my health care agent may not make health care decisions for me if
6my health care agent knows I am pregnant.
AB695,23,77
Health care decision if I am pregnant — Yes.... No....
AB695,23,108
If I have not checked either "Yes" or "No" immediately above, my health care
9agent may not make health care decisions for me if my health care agent knows I am
10pregnant.
AB695,23,11
11ACCESS TO DIGITAL ASSETS
AB695,23,15
12If I have checked "Yes" to the following, my health care agent may access the
13content of electronic communications on my behalf. If I have checked "No" to the
14following, my health care agent may not access the content of electronic
15communications on my behalf.
AB695,23,16
16Access to content of electronic communications — Yes.... No....
AB695,23,18
17If I have not checked either "Yes" or "No" immediately above, my agent may not
18access the content of electronic communications on my behalf.
AB695,23,2019
STATEMENT OF DESIRES,
20
SPECIAL PROVISIONS OR LIMITATIONS
AB695,23,2421
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):
AB695,24,53
INSPECTION AND DISCLOSURE OF
4
INFORMATION RELATING TO MY PHYSICAL
5
OR MENTAL HEALTH
AB695,24,76
Subject to any limitations in this document, my health care agent has the
7authority to do all of the following:
AB695,24,98
(a) Request, review and receive any information, oral or written, regarding my
9physical or mental health, including medical and hospital records.
AB695,24,1110
(b) Execute on my behalf any documents that may be required in order to obtain
11this information.
AB695,24,1212
(c) Consent to the disclosure of this information.
AB695,24,14
13(d) Access my digital assets, other than the content of my electronic
14communication, and catalogues of my electronic communications.
AB695,24,1515
(The principal and the witnesses all must sign the document at the same time.)
AB695,24,1616
SIGNATURE OF PRINCIPAL
AB695,24,1717
(person creating the power of attorney for health care)
AB695,24,1818
Signature.... Date....
AB695,24,2019
(The signing of this document by the principal revokes all previous powers of
20attorney for health care documents.)
AB695,24,2121
STATEMENT OF WITNESSES
AB695,25,722
I know the principal personally and I believe him or her to be of sound mind and
23at least 18 years of age. I believe that his or her execution of this power of attorney
24for health care is voluntary. I am at least 18 years of age, am not related to the
25principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
1of the principal, and am not directly financially responsible for the principal's health
2care. I am not a health care provider who is serving the principal at this time, an
3employee of the health care provider, other than a chaplain or a social worker, or an
4employee, other than a chaplain or a social worker, of an inpatient health care facility
5in which the declarant is a patient. I am not the principal's health care agent. To
6the best of my knowledge, I am not entitled to and do not have a claim on the
7principal's estate.
AB695,25,88
Witness No. 1:
AB695,25,99
(print) Name.... Date....
AB695,25,1010
Address....
AB695,25,1111
Signature....
AB695,25,1212
Witness No. 2:
AB695,25,1313
(print) Name.... Date....
AB695,25,1414
Address....
AB695,25,1515
Signature....
AB695,25,1716
STATEMENT OF HEALTH CARE AGENT AND
17
ALTERNATE HEALTH CARE AGENT
AB695,25,2118
I understand that.... (name of principal) has designated me to be his or her
19health care agent or alternate health care agent if he or she is ever found to have
20incapacity and unable to make health care decisions himself or herself. .... (name of
21principal) has discussed his or her desires regarding health care decisions with me.
AB695,25,2222
Agent's signature....
AB695,25,2323
Address....
AB695,25,2424
Alternate's signature....
AB695,25,2525
Address....
AB695,26,3
1Failure to execute a power of attorney for health care document under chapter
2155 of the Wisconsin Statutes creates no presumption about the intent of any
3individual with regard to his or her health care decisions.
AB695,26,54
This power of attorney for health care is executed as provided in chapter 155
5of the Wisconsin Statutes.
AB695,26,66
ANATOMICAL GIFTS (optional)
AB695,26,77
Upon my death:
AB695,26,98
.... I wish to donate only the following organs or parts: .... (specify the organs or
9parts).
AB695,26,1010
.... I wish to donate any needed organ or part.
AB695,26,1111
.... I wish to donate my body for anatomical study if needed.
AB695,26,1412
.... I refuse to make an anatomical gift. (If this revokes a prior commitment that
13I have made to make an anatomical gift to a designated donee, I will attempt to notify
14the donee to which or to whom I agreed to donate.)
AB695,26,1615
Failing to check any of the lines immediately above creates no presumption
16about my desire to make or refuse to make an anatomical gift.
AB695,26,1717
Signature.... Date....
AB695,5
18Section
5. 244.41 (1) (i) of the statutes is created to read:
AB695,26,2019
244.41
(1) (i) Access the content of an electronic communication, as defined in
20s. 112.12 (2) (f), sent or received by the principal.
AB695,6
21Section
6. 244.43 (9m) of the statutes is created to read:
AB695,26,2522
244.43
(9m) Access a catalogue of electronic communications, as defined in s.
23112.12 (2) (d), sent or received by the principal, and the principal's digital assets, as
24defined in s. 112.12 (2) (j), other than the content of electronic communications, as
25defined in s. 112.12 (2) (f)
.
AB695,7
1Section
7. 244.61 (form) of the statutes is amended to read:
AB695,27,2
2244.61 (form)
AB695,27,5
3WISCONSIN STATUTORY FORM
4
POWER OF ATTORNEY
5
FOR FINANCES AND PROPERTY
AB695,27,66
IMPORTANT INFORMATION
AB695,27,147
THIS POWER OF ATTORNEY AUTHORIZES ANOTHER PERSON (YOUR
8AGENT) TO MAKE DECISIONS CONCERNING YOUR PROPERTY FOR YOU
9(THE PRINCIPAL). YOUR AGENT WILL BE ABLE TO MAKE DECISIONS AND
10ACT WITH RESPECT TO YOUR PROPERTY (INCLUDING YOUR MONEY)
11WHETHER OR NOT YOU ARE ABLE TO ACT FOR YOURSELF. THE MEANING
12OF AUTHORITY OVER SUBJECTS LISTED ON THIS FORM IS EXPLAINED IN
13THE UNIFORM POWER OF ATTORNEY FOR FINANCES AND PROPERTY ACT
14IN CHAPTER 244 OF THE WISCONSIN STATUTES.
AB695,27,1615
THIS POWER OF ATTORNEY DOES NOT AUTHORIZE THE AGENT TO
16MAKE HEALTH-CARE DECISIONS FOR YOU.
AB695,27,2017
YOU SHOULD SELECT SOMEONE YOU TRUST TO SERVE AS YOUR
18AGENT. UNLESS YOU SPECIFY OTHERWISE, GENERALLY THE AGENT'S
19AUTHORITY WILL CONTINUE UNTIL YOU DIE OR REVOKE THE POWER OF
20ATTORNEY OR THE AGENT RESIGNS OR IS UNABLE TO ACT FOR YOU.
AB695,27,2221
YOUR AGENT IS ENTITLED TO REASONABLE COMPENSATION
22UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.
AB695,28,223
THIS FORM PROVIDES FOR DESIGNATION OF ONE AGENT. IF YOU
24WISH TO NAME MORE THAN ONE AGENT YOU MAY NAME A COAGENT IN
25THE SPECIAL INSTRUCTIONS. COAGENTS ARE NOT REQUIRED TO ACT
1TOGETHER UNLESS YOU INCLUDE THAT REQUIREMENT IN THE SPECIAL
2INSTRUCTIONS.
AB695,28,53
IF YOUR AGENT IS UNABLE OR UNWILLING TO ACT FOR YOU, YOUR
4POWER OF ATTORNEY WILL END UNLESS YOU HAVE NAMED A
5SUCCESSOR AGENT. YOU MAY ALSO NAME A 2ND SUCCESSOR AGENT.
AB695,28,106
THIS POWER OF ATTORNEY BECOMES EFFECTIVE IMMEDIATELY
7UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS. THIS
8POWER OF ATTORNEY DOES NOT REVOKE ANY POWER OF ATTORNEY
9EXECUTED PREVIOUSLY UNLESS YOU SO PROVIDE IN THE SPECIAL
10INSTRUCTIONS.
AB695,28,1611
IF YOU REVOKE THIS POWER OF ATTORNEY, YOU SHOULD NOTIFY
12YOUR AGENT AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A
13COPY. IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND
14YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR LEGALLY
15SEPARATED OR THE DOMESTIC PARTNERSHIP IS TERMINATED AFTER
16SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.
AB695,28,1917
IF YOU HAVE QUESTIONS ABOUT THE POWER OF ATTORNEY OR THE
18AUTHORITY YOU ARE GRANTING TO YOUR AGENT, YOU SHOULD SEEK
19LEGAL ADVICE BEFORE SIGNING THIS FORM.
AB695,28,2020
DESIGNATION OF AGENT
AB695,28,2121
I .... (name of principal) name the following person as my agent:
AB695,28,2222
Name of agent: ....
AB695,28,2323
Agent's address: ....
AB695,28,2424
Agent's telephone number: ....
AB695,28,2525
DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)
AB695,29,1
1If my agent is unable or unwilling to act for me, I name as my successor agent:
AB695,29,22
Name of successor agent: ....
AB695,29,33
Successor agent's address: ....
AB695,29,44
Successor agent's telephone number: ....
AB695,29,65
If my successor agent is unable or unwilling to act for me, I name as my 2nd
6successor agent:
AB695,29,77
Name of 2nd successor agent: ....
AB695,29,88
Second successor agent's address: ....
AB695,29,99
Second successor agent's telephone number: ....
