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Witness No. 1:
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(print) Name.... Date....
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Address....
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Signature....
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Witness No. 2:
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(print) Name.... Date....
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Address....
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Signature....
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STATEMENT OF HEALTH CARE AGENT AND
25
ALTERNATE HEALTH CARE AGENT
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1I understand that.... (name of principal) has designated me to be his or her
2health care agent or alternate health care agent if he or she is ever found to have
3incapacity and unable to make health care decisions himself or herself. .... (name of
4principal) has discussed his or her desires regarding health care decisions with me.
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Agent's signature....
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Alternate's signature....
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Failure to execute a power of attorney for health care document under chapter
10155 of the Wisconsin Statutes creates no presumption about the intent of any
11individual with regard to his or her health care decisions.
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This power of attorney for health care is executed as provided in chapter 155
13of the Wisconsin Statutes.
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ANATOMICAL GIFTS (optional)
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Upon my death:
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.... I wish to donate only the following organs or parts: .... (specify the organs or
17parts).
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.... I wish to donate any needed organ or part.
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.... I wish to donate my body for anatomical study if needed.
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.... I refuse to make an anatomical gift. (If this revokes a prior commitment that
21I have made to make an anatomical gift to a designated donee, I will attempt to notify
22the donee to which or to whom I agreed to donate.)
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Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
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Signature.... Date....
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1Section
31. 155.50 (1) (b) of the statutes is amended to read:
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155.50
(1) (b) Failing to comply with a power of attorney for health care
3instrument or the decision of a health care agent, except that failure of a
physician 4health care professional, as defined in s. 154.01 (3), to comply constitutes
5unprofessional conduct if the
physician health care professional refuses or fails to
6make a good faith attempt to transfer the principal to another
physician health care
7professional who will comply.
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8Section 32
. 165.77 (1) (a) of the statutes is amended to read:
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165.77
(1) (a) “Health care professional"
has the meaning given in s. 154.01 (3) 10means a person licensed, certified, or registered under ch. 441, 448, or 455.
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11Section 33
. 302.384 of the statutes is renumbered 302.384 (2m), and 302.384
12(2m) (a), as renumbered, is amended to read:
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302.384
(2m) (a) A sheriff, jailer, keeper or officer arranges for a health care
14professional
, as defined in s. 154.01 (3), to observe the prisoner.
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15Section 34
. 302.384 (1m) of the statutes is created to read:
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302.384
(1m) In this section, “health care professional” means a person
17licensed, certified, or registered under ch. 441, 448, or 455.
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18Section 35
. 441.07 (1g) (d) (intro.) of the statutes is amended to read:
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441.07
(1g) (d) (intro.) Misconduct or unprofessional conduct.
In this
20paragraph, “unprofessional conduct” includes making a determination under ch. 154
21or 155 if the person does not have sufficient education, training, and experience to
22make the determination. In this paragraph, “misconduct" and “unprofessional
23conduct" do not include any of the following:
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24Section
36. 448.015 (4) (am) 2m. of the statutes is created to read:
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1448.015
(4) (am) 2m. A determination made by a physician assistant under ch.
2154 or 155 if the physician assistant does not have sufficient education, training, and
3experience to make the determination.
