AB32,11,11 Signed: ....

AB32,11,12 Dated: ....

AB32,11,13 Statement and signatures

AB32,11,14 of witnesses

AB32,11,24 I know the requester personally or I have received proof of his or her identity and I believe him or her to be of sound mind and at least 18 years of age. I believe that the requester makes this request voluntarily. I am at least 18 years of age, am not related to the requester by blood, marriage or adoption and am not directly financially responsible for the requester's health care. I am not a health care provider who is serving the requester at this time, an employe of the health care provider, other than a chaplain or a social worker, or an employe, other than a chaplain or a social worker, of a health care facility in which the requester is a patient. To the best of my knowledge, I am not entitled to and do not have a claim on the requester's estate.

AB32,11,25 Witness No. 1:

AB32,12,1 (print) Name: ....

AB32,12,2 Address: ....

AB32,12,3 Signature: ....

AB32,12,4 Witness No. 2:

AB32,12,5 (print) Name: ....

AB32,12,6 Address: ....

AB32,12,7 Signature: ....

AB32,12,8 Witness No. 3:

AB32,12,9 (print) Name: ....

AB32,12,10 Address: ....

AB32,12,11 Signature: ....

AB32,12,15 If the requester is a patient in a health care facility, at least one of the above witnesses must be a patients' advocate designated by the board on aging and long-term care. A patients' advocate who is a witness should print "patients' advocate" after the printing of his or her name above.

AB32,12,17 156.17 Revocation of request for medication. (1) A requester may revoke his or her request for medication at any time by doing any of the following:

AB32,12,20 (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying the request for medication or directing another in the presence of the requester to so destroy the request for medication.

AB32,12,22 (b) Executing a statement, in writing, that is signed and dated by the requester, expressing the requester's intent to revoke the request for medication.

AB32,12,24 (c) Orally expressing the requester's intent to revoke the request for medication, in the presence of 2 witnesses.

AB32,12,25 (d) Making a subsequent request for medication.

AB32,13,4 (2) The requester's health care provider shall, upon notification of revocation of the requester's request for medication, record in the requester's medical record the time, date and place of the revocation and the time, date and place, if different, of the notification to the health care provider of the revocation.

AB32,13,11 156.19 Designation or patients' advocates. The board on aging and long-term care shall designate staff of the long-term care ombudsman program as patients' advocates. A person so designated shall serve as a witness to a request for medication of a requester who is a patient or resident of a nursing home or community-based residential facility, as required under s. 156.05 (2) (b), and shall speak on behalf of the requester to ensure that his or her needs or wants are communicated to and addressed by his or her attending physician.

AB32,13,14 156.21 Duties and immunities. (1) No health care facility or health care provider may be charged with a crime, held civilly liable or charged with unprofessional conduct for any of the following:

AB32,13,19 (a) Failing to fulfill a request for medication, except that failure of an attending physician to fulfill a request for medication constitutes unprofessional conduct if the attending physician refuses or fails to make a good-faith attempt to transfer the requester's care and treatment to another physician who will act as attending physician under this chapter and fulfill the request for medication.

AB32,13,21 (b) In the absence of actual knowledge of a revocation, fulfilling a request for medication that is in compliance with this chapter.

AB32,13,24 (c) Acting contrary to or failing to act on a revocation of a request for medication, unless the health care facility or health care provider has actual knowledge of the revocation.