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STATEMENT OF DESIRES,
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SPECIAL PROVISIONS OR LIMITATIONS
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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):
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INSPECTION AND DISCLOSURE OF
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INFORMATION RELATING TO MY PHYSICAL
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OR MENTAL HEALTH
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Subject to any limitations in this document, my health care agent has the
12authority to do all of the following:
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(a) Request, review and receive any information, oral or written, regarding my
14physical or mental health, including medical and hospital records.
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(b) Execute on my behalf any documents that may be required in order to obtain
16this information.
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(c) Consent to the disclosure of this information.
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(The principal and the witnesses all must sign the document at the same time.)
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SIGNATURE OF PRINCIPAL
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(person creating the power of attorney for health care)
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Signature.... Date....
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(The signing of this document by the principal revokes all previous powers of
23attorney for health care documents.)
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STATEMENT OF WITNESSES
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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.
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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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20ACKNOWLEDGMENT OF NOTARIAL OFFICER
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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.
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4(print) Name....
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5State of ....
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6County of ....
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7This document was acknowledged before me on .... (date), by .... (name of
8principal).
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9(Seal, if any)
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10Signature of notary ....
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11My commission expires: ....
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STATEMENT OF HEALTH CARE AGENT AND
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ALTERNATE HEALTH CARE AGENT
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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.
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Agent's signature....
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Address....
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Alternate's signature....
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Address....
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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.
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1This power of attorney for health care is executed as provided in chapter 155
2of 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
6parts).
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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
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.)
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Failing to check any of the lines immediately above creates no presumption
13about my desire to make or refuse to make an anatomical gift.
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Signature.... Date....
