AB655,8,53 is my supporter. For the following everyday life decisions, if I have checked
4“Yes,” my supporter may help me with that type of decision, but if I have checked
5“No,” my supporter may not help me with that type of decision:
AB655,8,66 Obtaining food, clothing, and shelter — Yes.... No....
AB655,8,77 Taking care of my physical health — Yes.... No....
AB655,8,88 Managing my financial affairs — Yes.... No....
AB655,8,99 Taking care of my mental health — Yes.... No....
AB655,8,1010 Applying for public benefits — Yes.... No....
AB655,8,1211 Assistance with seeking vocational rehabilitation services and other vocational
12supports — Yes.... No....
AB655,8,1413 The following are other decisions I have specifically identified that I would like
14assistance with ....
AB655,8,1715 If I have not checked either “Yes" or “No" or specifically identified and listed a
16decision immediately above, my supporter may not help me with that type of
17decision.
AB655,8,1918 My supporter is not allowed to make decisions for me. To help me with my
19decisions, my supporter may do any of the following, if I have checked “Yes”:
AB655,8,2420 1. Help me access, collect, or obtain information, including records, relevant to
21a decision. If I have checked “Yes,” my supporter may help me access, collect, or
22obtain the type of information specified, including relevant records, but if I have
23checked “No,” or I have not checked either “Yes” or “No,” my supporter may not help
24me access, collect, or obtain that type of information:
AB655,8,2525 Medical — Yes.... No....
AB655,9,1
1Psychological — Yes.... No....
AB655,9,22 Financial — Yes.... No....
AB655,9,33 Education — Yes.... No....
AB655,9,44 Treatment — Yes.... No....
AB655,9,65 Other — Yes.... No.... (If “Yes,” specify the other type(s) of information with
6which the supporter may assist ....)
AB655,9,87 2. Help me understand my options so I can make an informed decision.
8 Yes.... No....
AB655,9,109 3. Help me communicate my decision to appropriate persons.
10 Yes.... No....
AB655,9,1511 4. Help me access appropriate personal records, including protected health
12information under the Health Insurance Portability and Accountability Act, the
13Family Educational Rights and Privacy Act, and other records that may or may not
14require a release for specific decisions I want to make.
15 Yes.... No....
AB655,9,17 16Effective Date of Supported
17 Decision-Making Agreement
AB655,9,2018 This supported decision-making agreement is effective immediately and will
19continue until .... (insert date), or until the agreement is terminated by my supporter
20or me or by operation of law.
AB655,9,2121 (print) Name of person designating a supporter ....
AB655,9,2222 Signature ....
AB655,9,2323 Date ....
AB655,9,24 24consent of supporter
AB655,10,3
1I know .... (name of person) personally or I have received proof of his or her
2identity and I believe him or her to be at least 18 years of age and entering this
3agreement knowingly and voluntarily. I am at least 18 years of age.
AB655,10,44 I, .... (name of supporter), consent to act as a supporter under this agreement.
AB655,10,55 Supporter:
AB655,10,66 (print) Name ....
AB655,10,77 Address ....
AB655,10,88 E-mail address ....
AB655,10,99 Phone number(s) ....
AB655,10,1010 Signature ....
AB655,10,1111 Date ....
AB655,10,14 12Statement AND SIGNATURE
13 OF WITNESSES OR
14 SIGNATURE OF NOTARY
AB655,10,1615 (This agreement must be signed either by 2 witnesses who are at least 18 years
16of age or by a notary public.)
AB655,10,1717 OPTION I: WITNESSES
AB655,10,2018 I know .... (name of person) personally or I have received proof of his or her
19identity and I believe him or her to be at least 18 years of age and entering this
20agreement knowingly and voluntarily. I am at least 18 years of age.
AB655,10,2121 Witness No. 1:
AB655,10,2222 (print) Name ....
AB655,10,2323 Address ....
AB655,10,2424 Phone number(s) ....
AB655,10,2525 Signature ....
AB655,11,1
1Date ....
AB655,11,22 Witness No. 2:
AB655,11,33 (print) Name ....
AB655,11,44 Address ....
AB655,11,55 Phone number(s) ....
AB655,11,66 Signature ....
AB655,11,77 Date ....
AB655,11,88 OPTION II: NOTARY PUBLIC
AB655,11,99 State of ....
AB655,11,1010 County of ....
AB655,11,1211 This document was acknowledged before me on .... (date), by .... (name of adult
12with a functional impairment) and ..... (name of supporter).
AB655,11,1313 Signature of notary ....
AB655,11,1414 (Seal, if any, of notary)
AB655,11,1515 Printed name ....
AB655,11,1616 My commission expires: ....
AB655,11,22 17(2) The department of health services shall prepare and provide access to a
18supported decision-making agreement instrument and accompanying information
19for adults with functional impairments, family members of adults with functional
20impairments, education professionals and school districts, health care and social
21service professionals, county clerks, and local bar associations. The department may
22charge a reasonable fee for the cost of preparation and distribution.
AB655,11,2523 Subchapter III
24 duty of certain persons
25 with respect to agreement
AB655,12,5
153.30 Reliance on agreement; limitation of liability. (1) A person who
2receives the original or a copy of a supported decision-making agreement shall rely
3on the agreement, except if the person has cause to believe that the adult with a
4functional impairment is being abused, neglected, unduly influenced, or financially
5exploited by the supporter as described under s. 53.32.
AB655,12,8 6(2) A person is not subject to criminal or civil liability and has not engaged in
7professional misconduct for an act or omission if the act or omission is done in good
8faith and in reliance on a supported decision-making agreement.
AB655,12,15 9(3) Any health care provider that respects and acts consistently with the
10authority given to a supporter by a duly executed supported decision-making
11agreement shall be immune from any action alleging that the agreement was invalid
12unless the entity, custodian, or organization had actual knowledge or notice that the
13adult with a functional impairment had revoked such authorization, that the
14agreement was invalid, or that the supporter had committed abuse, neglect, or
15financial exploitation as described in s. 53.14 (2) (a).
AB655,12,23 16(4) Any health care provider that provides health care based on the consent of
17an adult with a functional impairment, made with supports and services provided
18through a duly executed supported decision-making agreement, shall be immune
19from any action alleging that the adult with a functional impairment lacked capacity
20to provide informed consent unless the entity, custodian, or organization had actual
21knowledge or notice that the adult with a functional impairment had revoked such
22authorization, that the agreement was invalid, or that the supporter had committed
23abuse, neglect, or financial exploitation as described in s. 53.14 (2) (a).
AB655,13,5 24(5) Any public or private entity, custodian, or organization that discloses
25personal information about an adult with a functional impairment to a supporter

1who is authorized to access, collect, or obtain or assist the adult with a functional
2impairment in accessing, collecting, or obtaining that information shall be immune
3from any action alleging that it improperly or unlawfully disclosed such information
4to the supporter unless the entity, custodian, or organization had actual knowledge
5that the adult with a functional impairment had revoked such authorization.
AB655,13,7 6(6) This section may not be construed to provide immunity from actions
7alleging that a health care provider has done any of the following:
AB655,13,98 (a) Caused personal injury as a result of a negligent, reckless, or intentional
9act.
AB655,13,1110 (b) Acted inconsistently with the expressed wishes of an adult with a functional
11impairment.
AB655,13,1312 (c) Failed to provide information to either an adult with a functional
13impairment or his or her supporter that would be necessary for informed consent.
AB655,13,1414 (d) Otherwise acted inconsistently with applicable law.
AB655,13,20 15(7) The existence or availability of a supported decision-making agreement
16does not relieve a health care provider of any legal obligation to provide services to
17individuals with disabilities, including the obligation to provide reasonable
18accommodations or auxiliary aids and services, including interpretation services
19and communication supports to individuals with disabilities under the federal
20Americans with Disabilities Act.
AB655,14,2 21(8) A supporter acting in the context of a valid supported decision-making
22agreement is immune from civil liability for his or her acts or omissions in performing
23duties as the supporter if he or she performs the duties in good faith, in conformance
24with the supported decision-making agreement or document of the adult with a

1functional impairment, and with the degree and prudence that an ordinarily prudent
2person exercises in his or her own affairs.
AB655,14,8 353.32 Reporting of suspected abuse, neglect, or financial exploitation.
4(1) If a person who receives a copy of a supported decision-making agreement or is
5aware of the existence of a supported decision-making agreement has cause to
6believe that the adult with a functional impairment is being abused, neglected, or
7financially exploited by the supporter, the person may report under s. 46.90 or 55.043
8the alleged abuse, neglect, or financial exploitation.
AB655,14,10 9(2) Nothing in this section may be construed as eliminating or limiting a
10person's requirement to report under any other statute or regulation.
AB655,2 11Section 2. 54.10 (2) (b) 9m. of the statutes is created to read:
AB655,14,1712 54.10 (2) (b) 9m. Whether any alternatives to guardianship, including
13supported decision-making under ch. 53, have been attempted, and, if applicable,
14the degree to which they have been attempted, the length of time they have been
15attempted, and whether they have been attempted in a manner sufficient to
16demonstrate that alternatives to guardianship are insufficient to enable the
17individual to adequately exercise the right or rights in question.
AB655,3 18Section 3 . 54.10 (3) (a) 4. of the statutes is amended to read:
AB655,14,2319 54.10 (3) (a) 4. The individual's need for assistance in decision making or
20communication is unable to be met effectively and less restrictively through
21appropriate and reasonably available training, education, support services, health
22care, assistive devices, a supported decision-making agreement under ch. 53, or
23other means that the individual will accept.
AB655,4 24Section 4 . 54.10 (3) (b) of the statutes is amended to read:
AB655,15,4
154.10 (3) (b) Unless the proposed ward is unable to communicate decisions
2effectively in any way, the determination under par. (a) may not be based on mere old
3age, eccentricity, poor judgment, or physical disability, or the existence of a supported
4decision-making agreement
.
AB655,5 5Section 5. 115.807 (4) of the statutes is created to read:
AB655,15,96 115.807 (4) The local educational agency shall provide the individual and the
7individual's parents with information on supported decision-making under ch. 53,
8other alternatives to guardianship, and strategies to remain engaged in the
9individual's secondary education.
AB655,15,1010 (End)
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