SB655,10,1010 POWER OF ATTORNEY FOR HEALTH CARE
SB655,10,1111 Document made this.... day of.... (month),.... (year).
SB655,10,1212 CREATION OF POWER OF ATTORNEY
SB655,10,1313 FOR HEALTH CARE
SB655,10,2114 I,.... (print name, address and date of birth), being of sound mind, intend by this
15document to create a power of attorney for health care. My executing this power of
16attorney for health care is voluntary. Despite the creation of this power of attorney
17for health care, I expect to be fully informed about and allowed to participate in any
18health care decision for me, to the extent that I am able. For the purposes of this
19document, “health care decision" means an informed decision to accept, maintain,
20discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
21or treat my physical or mental condition.
SB655,10,2322 In addition, I may, by this document, specify my wishes with respect to making
23an anatomical gift upon my death.
SB655,10,2424 DESIGNATION OF HEALTH CARE AGENT
SB655,11,15
1If I am no longer able to make health care decisions for myself, due to my
2incapacity, I hereby designate.... (print name, address and telephone number) to be
3my health care agent for the purpose of making health care decisions on my behalf.
4If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
5address and telephone number) to be my alternate health care agent for the purpose
6of making health care decisions on my behalf. Neither my health care agent nor my
7alternate health care agent whom I have designated is my health care provider, an
8employee of my health care provider, an employee of a health care facility in which
9I am a patient or a spouse of any of those persons, unless he or she is also my relative.
10For purposes of this document, “incapacity" exists if 2 physicians or a physician and
11a psychologist who have personally examined me sign a statement that specifically
12expresses their opinion that I have a condition that means that I am unable to receive
13and evaluate information effectively or to communicate decisions to such an extent
14that I lack the capacity to manage my health care decisions. A copy of that statement
15must be attached to this document.
SB655,11,1616 GENERAL STATEMENT OF AUTHORITY GRANTED
SB655,11,2317 Unless I have specified otherwise in this document, if I ever have incapacity I
18instruct my health care provider to obtain the health care decision of my health care
19agent, if I need treatment, for all of my health care and treatment. I have discussed
20my desires thoroughly with my health care agent and believe that he or she
21understands my philosophy regarding the health care decisions I would make if I
22were able. I desire that my wishes be carried out through the authority given to my
23health care agent under this document.
SB655,12,724 If I am unable, due to my incapacity, to make a health care decision, my health
25care agent is instructed to make the health care decision for me, but my health care

1agent should try to discuss with me any specific proposed health care if I am able to
2communicate in any manner, including by blinking my eyes. If this communication
3cannot be made, my health care agent shall base his or her decision on any health
4care choices that I have expressed prior to the time of the decision. If I have not
5expressed a health care choice about the health care in question and communication
6cannot be made, my health care agent shall base his or her health care decision on
7what he or she believes to be in my best interest.
SB655,12,88 LIMITATIONS ON MENTAL HEALTH TREATMENT
SB655,12,149 My health care agent may not admit or commit me on an inpatient basis to an
10institution for mental diseases, an intermediate care facility for persons with an
11intellectual disability, a state treatment facility or a treatment facility. My health
12care agent may not consent to experimental mental health research or
13psychosurgery, electroconvulsive treatment or drastic mental health treatment
14procedures for me.
SB655,12,1515 ADMISSION TO NURSING HOMES OR
SB655,12,1616 COMMUNITY-BASED RESIDENTIAL FACILITIES
SB655,12,1817 My health care agent may admit me to a nursing home or community-based
18residential facility for short-term stays for recuperative care or respite care.
SB655,12,2119 If I have checked “Yes" to the following, my health care agent may admit me for
20a purpose other than recuperative care or respite care, but if I have checked “No" to
21the following, my health care agent may not so admit me:
SB655,12,2222 1. A nursing home — Yes.... No....
SB655,12,2323 2. A community-based residential facility — Yes.... No....
SB655,12,2524 If I have not checked either “Yes" or “No" immediately above, my health care
25agent may admit me only for short-term stays for recuperative care or respite care.
SB655,13,1
1PROVISION OF A FEEDING TUBE
SB655,13,62 If I have checked “Yes" to the following, my health care agent may have a
3feeding tube withheld or withdrawn from me, unless my physician has advised that,
4in his or her professional judgment, this will cause me pain or will reduce my comfort.
5If I have checked “No" to the following, my health care agent may not have a feeding
6tube withheld or withdrawn from me.
SB655,13,97 My health care agent may not have orally ingested nutrition or hydration
8withheld or withdrawn from me unless provision of the nutrition or hydration is
9medically contraindicated.
SB655,13,1010 Withhold or withdraw a feeding tube — Yes.... No....
SB655,13,1211 If I have not checked either “Yes" or “No" immediately above, my health care
12agent may not have a feeding tube withdrawn from me.
SB655,13,1313 HEALTH CARE DECISIONS FOR
SB655,13,1414 PREGNANT WOMEN
SB655,13,1815 If I have checked “Yes" to the following, my health care agent may make health
16care decisions for me even if my agent knows I am pregnant. If I have checked “No"
17to the following, my health care agent may not make health care decisions for me if
18my health care agent knows I am pregnant.
SB655,13,1919 Health care decision if I am pregnant — Yes.... No....
SB655,13,2220 If I have not checked either “Yes" or “No" immediately above, my health care
21agent may not make health care decisions for me if my health care agent knows I am
22pregnant.
SB655,13,2323 STATEMENT OF DESIRES,
SB655,13,2424 SPECIAL PROVISIONS OR LIMITATIONS
SB655,14,4
1In exercising authority under this document, my health care agent shall act
2consistently with my following stated desires, if any, and is subject to any special
3provisions or limitations that I specify. The following are specific desires, provisions
4or limitations that I wish to state (add more items if needed):
SB655,14,55 1) -
SB655,14,66 2) -
SB655,14,77 3) -
SB655,14,88 INSPECTION AND DISCLOSURE OF
SB655,14,99 INFORMATION RELATING TO MY PHYSICAL
SB655,14,1010 OR MENTAL HEALTH
SB655,14,1211 Subject to any limitations in this document, my health care agent has the
12authority to do all of the following:
SB655,14,1413 (a) Request, review and receive any information, oral or written, regarding my
14physical or mental health, including medical and hospital records.
SB655,14,1615 (b) Execute on my behalf any documents that may be required in order to obtain
16this information.
SB655,14,1717 (c) Consent to the disclosure of this information.
SB655,14,1818 (The principal and the witnesses all must sign the document at the same time.)
SB655,14,1919 SIGNATURE OF PRINCIPAL
SB655,14,2020 (person creating the power of attorney for health care)
SB655,14,2121 Signature....  Date....
SB655,14,2322 (The signing of this document by the principal revokes all previous powers of
23attorney for health care documents.)
SB655,14,2424 STATEMENT OF WITNESSES
SB655,15,11
1I know the principal personally and I believe him or her to be of sound mind and
2at least 18 years of age. I believe that his or her execution of this power of attorney
3for health care is voluntary. I am at least 18 years of age, am not related to the
4principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
5of the principal, and am not directly financially responsible for the principal's health
6care. I am not a health care provider who is serving the principal at this time, an
7employee of the health care provider, other than a chaplain or a social worker, or an
8employee, other than a chaplain or a social worker, of an inpatient health care facility
9in which the declarant principal is a patient. I am not the principal's health care
10agent. To the best of my knowledge, I am not entitled to and do not have a claim on
11the principal's estate.
SB655,15,1212 Witness No. 1:
SB655,15,1313 (print) Name.... Date....
SB655,15,1414 Address....
SB655,15,1515 Signature....
SB655,15,1616 Witness No. 2:
SB655,15,1717 (print) Name.... Date....
SB655,15,1818 Address....
SB655,15,1919 Signature....
SB655,15,20 20ACKNOWLEDGMENT OF NOTARIAL OFFICER
SB655,16,3 21I know the principal personally and I believe him or her to be of sound mind and
22at least 18 years of age. I am at least 18 years of age, am not related to the principal
23by blood, marriage, or adoption, am not the domestic partner under ch. 770 of the
24principal, and am not directly financially responsible for the principal's health care.
25I am not a health care provider who is serving the principal at this time. I am not

1a finance or billing officer of an inpatient health care facility in which the principal
2is a patient. I am not the principal's health care agent. To the best of my knowledge,
3I am not entitled to and do not have a claim on the principal's estate.
SB655,16,4 4(print) Name....
SB655,16,5 5State of ....
SB655,16,6 6County of ....
SB655,16,8 7This document was acknowledged before me on .... (date), by .... (name of
8principal).
SB655,16,9 9(Seal, if any)
SB655,16,10 10Signature of notary ....
SB655,16,11 11My commission expires: ....
SB655,16,1212 STATEMENT OF HEALTH CARE AGENT AND
SB655,16,1313 ALTERNATE HEALTH CARE AGENT
SB655,16,1714 I understand that.... (name of principal) has designated me to be his or her
15health care agent or alternate health care agent if he or she is ever found to have
16incapacity and unable to make health care decisions himself or herself. .... (name of
17principal) has discussed his or her desires regarding health care decisions with me.
SB655,16,1818 Agent's signature....
SB655,16,1919 Address....
SB655,16,2020 Alternate's signature....
SB655,16,2121 Address....
SB655,16,2422 Failure to execute a power of attorney for health care document under chapter
23155 of the Wisconsin Statutes creates no presumption about the intent of any
24individual with regard to his or her health care decisions.
SB655,17,2
1This power of attorney for health care is executed as provided in chapter 155
2of the Wisconsin Statutes.
SB655,17,33 ANATOMICAL GIFTS (optional)
SB655,17,44 Upon my death:
SB655,17,65 .... I wish to donate only the following organs or parts: .... (specify the organs or
6parts).
SB655,17,77 .... I wish to donate any needed organ or part.
SB655,17,88 .... I wish to donate my body for anatomical study if needed.
SB655,17,119 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
10I have made to make an anatomical gift to a designated donee, I will attempt to notify
11the donee to which or to whom I agreed to donate.)
SB655,17,1312 Failing to check any of the lines immediately above creates no presumption
13about my desire to make or refuse to make an anatomical gift.
SB655,17,1414 Signature....     Date....
SB655,17,1515 (End)
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