Fillable Printable Power of Attorney Form for Health Care - Wisconsin

Power of Attorney Form for Health Care - Wisconsin

DIVISION OF PUBLIC HEALTH

1 WEST WILSON STREET

P O BOX 2659

Scott Walker MADISON WI 53701-2659

Governor

State of Wisconsin 608-266-1251

Kitty Rhoades FAX: 608-267-2832

Secretary TTY: 888-701-1253

Department of Health Services dhs.wisconsin.gov

Wisconsin.gov

Instructions to Complete the Power of Attorney for Health Care Form

To Whom It May Concern:

Enclosed is the Power of Attorney for Health Care form you requested. The Power of Attorney for Health

Care form makes it possible for adults in Wisconsin to authorize other individuals (called health care

agents) to make health care decisions on their behalf should they become incapacitated. It may also be

used to make or refuse to make an anatomical gift (donation of all or part of the human body to take effect

upon the death of the donor).

Be sure to read all six (6) pages of the form carefully and understand it before you complete and sign it.

Talk with those you select as your health care agent and the alternate health care agent about your

thoughts and beliefs about medical treatment. Neither the health care agent nor the alternate may be your

health care provider, an employee of a health care facility in which you are a patient, or a spouse of any of

those persons, unless he or she is also your relative.

Two witnesses are required. Witnesses must be at least 18 years of age, not related to you by blood,

marriage, domestic partnership, or adoption, and not directly financially responsible for your health care.

A witness cannot be a health care provider who is serving you at the time the document is signed or an

employee of the health care provider unless the employee is a chaplain or social worker. A witness cannot

be an employee of an inpatient health care facility in which you are a patient, unless the employee is a

chaplain or social worker. A witness cannot be your health care agent or have a claim on any portion of

your estate. Valid witnesses acting in good faith are immune from civil or criminal liability.

An original signed form may be kept on file with your physician. A signed Power of Attorney for Health

Care form may also be kept in a safe, easily accessible place until needed. You should make relatives and

friends aware that you have created a Power of Attorney for Health Care and the location where it is kept.

Relatives and friends should also be told whom you select as the health care agent and the alternate. The

document may, but is not required to be, filed for safekeeping, for a fee, with the Register in Probate of

your county of residence. The fee for filing with the Register in Probate has been set by State Statute at

$8.00. A Power of Attorney for Health Care that is an original signed form or is a legible photocopy or

electronic facsimile copy is presumed to be valid. If you have both a Power of Attorney for Health Care

and a Declaration to Physicians, the provisions of a valid Power of Attorney for Health Care supersede

any directly conflicting provisions of a valid Declaration to Physicians.

One copy of the Power of Attorney for Health Care form is available free to anyone who sends a stamped,

self-addressed, business-size envelope to: Power of Attorney, Division of Public Health, P.O. Box 2659,

Madison, Wisconsin 53701-2659. You may make additional blank copies of the form you receive from

the Division of Public Health. The form is also available on the Department of Health Services Web page,

https://www.dhs.wisconsin.gov/forms/advdirectives/index.htm. If you have any questions about the

availability of the Power of Attorney for Health Care form or obtaining larger quantities of the form, you

may contact the Division of Public Health by telephoning 608-266-1251.

Definitions. ‘Department’ means the Department of Health Services. ‘Health Care’ means any care,

treatment, service, or procedure to maintain, diagnose, or treat an individual’s physical or mental

condition. ‘Health care decision’ means an informed decision in the exercise of the right to accept,

maintain, discontinue, or refuse health care. ‘Health care facility’ means a facility, as defined in State

Statute 647.01(4), or any hospital, nursing home, community-based residential facility, county home,

county infirmary, county hospital, county mental health center, tuberculosis sanatorium or other place

licensed or approved by the department under State Statutes 49.70, 49.71, 49.72, 50.02, 50.03, 50.35,

51.08, 51.09, 58.06, 252.073 or 252.076 or a facility under s. 45.365, 51.05, 51.06, 233.40, 233.41.

233.42 or 252.10. ‘Health care provider’ means a nurse licensed or permitted under State Statute Chapter

441, a chiropractor licensed under Chapter 446, a dentist licensed under Chapter 447, a physician,

podiatrist or physical therapist licensed or an occupational therapist or occupational therapy assistant

certified under Chapter 448, a person practicing Christian Science treatment, an optometrist licensed

under Chapter 449, a psychologist licensed under Chapter 455, a partnership thereof, a corporation

thereof that provides health care services, an operational cooperative sickness care plan organized under

State Statute 185.981 to 185.985 that directly provides services through salaried employees in its own

facility, or a home health agency, as defined in State Statute 50.49 (1) (a). ‘Incapacity’ means the

inability to receive and evaluate information effectively or to communicate decisions to such an extent

that the individual lacks the capacity to manage his or her health care decisions. ‘Feeding tube’ means a

medical tube through which nutrition or hydration is administered into the vein, stomach, nose, mouth or

other body opening of the declarant.

Who may sign a Power of Attorney for Health Care? An individual who is of sound mind and has

attained age 18 may voluntarily execute a Power of Attorney for Health Care. An individual for whom an

adjudication of incompetence and appointment of a guardian of the person is in effect under State Statute

Chapter 880 is presumed not to be of sound mind.

Procedures for signing a Power of Attorney for Health Care. The principal (person creating the Power

of Attorney for Health Care) and the witnesses all must sign the form at the same time.

When does it take effect? Unless otherwise specified in the Power of Attorney for Health Care

instrument (form), an individual’s Power of Attorney for Health Care takes effect upon a finding of

incapacity by 2 physicians, as defined in State Statute 448.01 (5), or one physician and one licensed

psychologist, as defined in State Statute.455.01 (4), who personally examine the principal and sign a

statement specifying that the principal has incapacity. Mere old age, eccentricity, or physical disability,

either singly or together, is insufficient to make a finding of incapacity. Neither of the individuals who

make a finding of incapacity may be a relative of the principal nor have knowledge that he or she is

entitled to or has a claim on any portion of the principal’s estate. A copy of the statement, if made, shall

be appended to the Power of Attorney for Health Care instrument.

Revocation. A principal may revoke his or her Power of Attorney for Health Care and invalidate the

Power of Attorney for Health Care instrument at any time by doing any of the following: canceling,

defacing, obliterating, burning, tearing or otherwise destroying the Power of Attorney for Health Care

instrument or directing another in the presence of the principal to so destroy the Power of Attorney for

Health Care instrument; executing a statement, in writing, that is signed and dated by the principal,

expressing the principal’s intent to revoke the Power of Attorney for Health Care; verbally expressing the

principal’s intent to revoke the Power of Attorney for Health Care in the presence of 2 witnesses; or,

executing a subsequent Power of Attorney for Health Care instrument. The principal’s health care

provider shall, upon notification of revocation of the principal’s Power of Attorney for Health Care

instrument, record in the principal’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.

Immunities. 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: certifying incapacity under State

Statute 155.05 (2), if the certification is made in good faith based on a thorough examination of the

principal; failing to comply with a Power of Attorney for Health Care instrument or the decision of a

health care agent, except that failure of a physician to comply constitutes unprofessional conduct if the

physician refuses or fails to make a good faith attempt to transfer the principal to another physician who

will comply; complying, in the absence of actual knowledge of a revocation, with the terms of a Power of

Attorney for Health Care instrument that is in compliance with Chapter 155; complying with the decision

of a health care agent that is made under a Power of Attorney for Health Care that is in compliance with

Chapter 155; acting contrary to or failing to act on a revocation of a Power of Attorney for Health Care,

unless the health care facility or health care provider has actual knowledge of the revocation; or, failing to

obtain the health care decision for a principal from the principal’s health care agent, if the health care

facility or health care provider has made a reasonable attempt to contact the health care agent and obtain

the decision but has been unable to do so. No health care agent may be charged with a crime or held

civilly liable for making a decision in good faith under a Power of Attorney for Health Care instrument

that is in compliance with Chapter 155. No health care agent who is not the spouse of the principal may

be held personally liable for any goods or services purchased or contracted for under a Power of Attorney

for Health Care instrument.

General provisions. The making of a health care decision on behalf of a principal under the principal’s

Power of Attorney for Health Care instrument does not, for any purpose, constitute suicide. No individual

may be required to execute a Power of Attorney for Health Care as a condition for receipt of health care

or admission to a health care facility. No insurer may refuse to pay for goods or services covered under a

principal’s insurance policy solely because the decision to use the goods or services was made by the

principal’s health care agent.

F-40085A (Rev. 01/2015)

Important:

You must keep pages 1-6 of the form together as your executed

document. Copies distributed to health care providers, etc. must

include pages 1- 6.

DEPARTMENT OF HEALTH SERVICES

Division of Public Health

F-00085 (Rev. 06/11)

STATE OF WISCONSIN

Chapter 155.30(1),(3)

Effective Date August 3, 2009

608 266-1251

POWER OF ATTORNEY FOR HEALTH CARE DOCUMENT

NOTICE TO PERSON MAKING THIS DOCUMENT

You have the right to make decisions about your health care. No health care may be

given to you over your objection, and necessary health care may not be stopped or

withheld if you object.

Because your health care providers in some cases may not have had the opportunity to

establish a long-term relationship with you, they are often unfamiliar with your beliefs

and values and the details of your family relationships. This poses a problem if you

become physically or mentally unable to make decisions about your health care.

In order to avoid this problem, you may sign this legal document to specify the person

whom you want to make health care decisions for you if you are unable to make those

decisions personally. That person is known as your health care agent. You should take

some time to discuss your thoughts and beliefs about medical treatment with the person

or persons whom you have specified. You may state in this document any types of health

care that you do or do not desire, and you may limit the authority of your health care

agent. If your health care agent is unaware of your desires with respect to a particular

health care decision, he or she is required to determine what would be in your best

interests in making the decision.

This is an important legal document. It gives your agent broad powers to make health

care decisions for you. It revokes any prior power of attorney for health care that you

may have made. If you wish to change your power of attorney for health care, you may

revoke this document at any time by destroying it, by directing another person to

destroy it in your presence, by signing a written and dated statement or by stating that it

is revoked in the presence of two witnesses. If you revoke, you should notify your agent,

health care provider(s), and any other person(s) to whom you have given a copy. If your

agent is your spouse or your domestic partner and your marriage is annulled or you are

divorced or your domestic partnership is terminated after signing this document, the

document is invalid.

You may also use this document to make or refuse to make an anatomical gift upon your

death. If you use this document to make or refuse to make an anatomical gift, this

document revokes any prior record of gift that you may have made. You may revoke or

change any anatomical gift that you make by this document by crossing out the

anatomical gifts provision in this document.

Do not sign this document unless you clearly understand it. It is suggested that you keep

the original of this document on file with your physician.

F-00085 (Rev. 06/11)

Page 2 of 6

POWER OF ATTORNEY FOR HEALTH CARE

Document made this day of (month), (year).

CREATION OF POWER OF ATTORNEY FOR HEALTH CARE

(print name, address, and date of birth), being of sound mind, intend by this document to create a

power of attorney for health care. My executing this power of attorney for health care is voluntary.

Despite the creation of this power of attorney for health care, I expect to be fully informed about

and allowed to participate in any health care decision for me, to the extent that I am able. For the

purposes of this document, “health care decision” means an informed decision to accept, maintain,

discontinue, or refuse any care, treatment, service, or procedure to maintain, diagnose, or treat my

physical or mental condition.

In addition, I may, by this document, specify my wishes with respect to making an anatomical

gift upon my death.

DESIGNATION OF HEALTH CARE AGENT

If I am no longer able to make health care decisions for myself, due to my incapacity, I

hereby designate

print name, address and telephone number) to be my health care agent for the purpose of making

health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I

hereby designate

(print name, address and telephone number) to be my alternate health care agent for the purpose

of making health care decisions on my behalf. Neither my health care agent nor my alternate

health care agent whom I have designated is my health care provider, an employee of my health

care provider, an employee of a health care facility in which I am a patient or a spouse of any of

those persons, unless he or she is also my relative. For purposes of this document, “incapacity”

exists if 2 physicians or a physician and a psychologist who have personally examined me sign a

statement that specifically expresses their opinion that I have a condition that means that I am

unable to receive and evaluate information effectively or to communicate decisions to such an

extent that I lack the capacity to manage my health care decisions. A copy of that statement must

be attached to this document.

F-00085 (Rev. 06/11)

Page 3 of 6

GENERAL STATEMENT OF AUTHORITY GRANTED

Unless I have specified otherwise in this document, if I ever have incapacity I instruct my

health care provider to obtain the health care decision of my health care agent, if I need

treatment, for all of my health care and treatment. I have discussed my desires thoroughly with

my health care agent and believe that he or she understands my philosophy regarding the health

care decisions I would make if I were able. I desire that my wishes be carried out through the

authority given to my health care agent under this document.

If I am unable, due to my incapacity, to make a health care decision, my health care agent is

instructed to make the health care decision for me, but my health care agent should try to discuss

with me any specific proposed health care if I am able to communicate in any manner, including

by blinking my eyes. If this communication cannot be made, my health care agent shall base his or

her decision on any health care choices that I have expressed prior to the time of the decision. If I

have not expressed a health care choice about the health care in question and communication

cannot be made, my health care agent shall base his or her health care decision on what he or she

believes to be in my best interest.

LIMITATIONS ON MENTAL HEALTH TREATMENT

My health care agent may not admit or commit me on an inpatient basis to an institution for

mental diseases, an intermediate care facility for the persons with mental retardation, a state

treatment facility, or a treatment facility. My health care agent may not consent to experimental

mental health research or psychosurgery, electroconvulsive treatment or drastic mental health

treatment procedures for me.

ADMISSION TO NURSING HOMES OR

COMMUNITY-BASED RESIDENTIAL FACILITIES

My health care agent may admit me to a nursing home or community-based residential facility

for short-term stays for recuperative care or respite care.

If I have checked “Yes” to the following, my health care agent may admit me for a purpose

other than recuperative care or respite care, but if I have checked “No” to the following, my health

care agent may not so admit me:

1. A nursing home - - Yes No

2. A community-based residential facility - - Yes No

If I have not checked either “Yes” or “No” immediately above, my health care agent may admit

me only for short-term stays for recuperative care or respite care.

F-00085 (Rev. 06/11)

Page 4 of 6

PROVISION OF FEEDING TUBE

If I have checked “Yes” to the following, my health care agent may have a feeding tube

withheld or withdrawn from me, unless my physician has advised that, in his or her professional

judgment, this will cause me pain or will reduce my comfort. If I have checked “No” to the

following, my health care agent may not have a feeding tube withheld or withdrawn from me.

My health care agent may not have orally ingested nutrition or hydration withheld or

withdrawn from me unless provision of the nutrition or hydration is medically contraindicated.

Withhold or withdraw a feeding tube - - Yes No

If I have not checked either “Yes” or “No” immediately above, my health care agent may not

have a feeding tube withdrawn from me.

HEALTH CARE DECISIONS FOR PREGNANT WOMEN

If I have checked “Yes” to the following, my health care agent may make health care decisions

for me even if my agent knows I am pregnant. If I have checked “No” to the following, my health

care agent may not make health care decisions for me if my health care agent knows I am

pregnant.

Health care decision if I am pregnant - - Yes No

If I have not checked either “Yes” or “No” immediately above, my health care agent may not

make health care decisions for me if my health care agent knows I am pregnant.

STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS

In exercising authority under this document, my health care agent shall act consistently with

my following stated desires, if any, and is subject to any special provisions or limitations that I

specify. The following are any specific desires, provisions or limitations that I wish to state (add

more items if needed):

INSPECTION AND DISCLOSURE OF INFORMATION

RELATING TO MY PHYSICAL OR MENTAL HEALTH

Subject to any limitations in this document, my health care agent has the authority to do all of

the following:

(a) Request, review, and receive any information, oral or written, regarding my physical or

mental health, including medical and hospital records.

(b) Execute on my behalf any documents that may be required in order to obtain this

information.

(c)

Consent to the disclosure of this information.

F-00085 (Rev. 06/11)

Page 5 of 6

(The principal and the witnesses all must sign the document at the same time.)

SIGNATURE OF PRINCIPAL

(Person creating the Power of Attorney for Health Care)

Signature Date

(The signing of this document by the principal revokes all previous powers of attorney for health

care documents.)

STATEMENT OF WITNESSES

I know the principal personally and I believe him or her to be of sound mind and at least 18

years of age. I believe that his or her execution of this power of attorney for health care is

voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage,

domestic partnership, or adoption, and am not directly financially responsible for the principal's

health care. I am not a health care provider who is serving the principal 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 an inpatient health care facility in which the declarant is a patient.

I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do

not have a claim on the principal's estate.

Witness Number 1

(Print) Name Date

Address

Signature

Witness Number 2

(Print) Name

Date

Address

Signature

STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT

principal) has designated me to be his or her health care agent or alternate health care agent if he

or she is ever found to have incapacity and unable to make health care decisions himself or

herself (name of principal) has

discussed his or her desires regarding health care decisions with me.

Agent's Signature

Address

Alternate's Signature

Address

I understand that (name of

F-00085 (Rev. 06/11)

Page 6 of 6

Failure to execute a power of attorney for health care document under chapter 155 of the

Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or

her health care decisions.

This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin

Statutes.

ANATOMICAL GIFTS (optional)

Upon my death:

I wish to donate only the following organs or parts: (specify the organs or parts).

I wish to donate any needed organ or part.

I wish to donate my body for anatomical study if needed.

I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to

make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to

whom I agreed to donate.)

Failing to check any of the lines immediately above creates no presumption about my desire to

make or refuse to make an anatomical gift.

Signature Date