SB655: Bill Text

SB655,13,22 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.

SB655,13,23 STATEMENT OF DESIRES,

SB655,13,24 SPECIAL PROVISIONS OR LIMITATIONS

SB655,14,4 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 specific desires, provisions or limitations that I wish to state (add more items if needed):

SB655,14,5 1) -

SB655,14,6 2) -

SB655,14,7 3) -

SB655,14,8 INSPECTION AND DISCLOSURE OF

SB655,14,9 INFORMATION RELATING TO MY PHYSICAL

SB655,14,10 OR MENTAL HEALTH

SB655,14,12 Subject to any limitations in this document, my health care agent has the authority to do all of the following:

SB655,14,14 (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records.

SB655,14,16 (b) Execute on my behalf any documents that may be required in order to obtain this information.

SB655,14,17 (c) Consent to the disclosure of this information.

SB655,14,18 (The principal and the witnesses all must sign the document at the same time.)

SB655,14,19 SIGNATURE OF PRINCIPAL

SB655,14,20 (person creating the power of attorney for health care)

SB655,14,21 Signature....  Date....

SB655,14,23 (The signing of this document by the principal revokes all previous powers of attorney for health care documents.)

SB655,14,24 STATEMENT OF WITNESSES

SB655,15,11 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, or adoption, am not the domestic partner under ch. 770 of the principal, 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 employee of the health care provider, other than a chaplain or a social worker, or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant principal 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.

SB655,15,12 Witness No. 1:

SB655,15,13 (print) Name.... Date....

SB655,15,14 Address....

SB655,15,15 Signature....

SB655,15,16 Witness No. 2:

SB655,15,17 (print) Name.... Date....

SB655,15,18 Address....

SB655,15,19 Signature....

SB655,15,20 ACKNOWLEDGMENT OF NOTARIAL OFFICER

SB655,16,3 I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I am at least 18 years of age, am not related to the principal by blood, marriage, or adoption, am not the domestic partner under ch. 770 of the principal, 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. I am not a finance or billing officer of an inpatient health care facility in which the principal 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.

SB655,16,4 (print) Name....

SB655,16,5 State of ....

SB655,16,6 County of ....

SB655,16,8 This document was acknowledged before me on .... (date), by .... (name of principal).

SB655,16,9 (Seal, if any)

SB655,16,10 Signature of notary ....

SB655,16,11 My commission expires: ....

SB655,16,12 STATEMENT OF HEALTH CARE AGENT AND

SB655,16,13 ALTERNATE HEALTH CARE AGENT

SB655,16,17 I understand that.... (name of 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.

SB655,16,18 Agent's signature....

SB655,16,19 Address....

SB655,16,20 Alternate's signature....

SB655,16,21 Address....

SB655,16,24 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.

SB655,17,2 This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes.

SB655,17,3 ANATOMICAL GIFTS (optional)

SB655,17,4 Upon my death:

SB655,17,6 .... I wish to donate only the following organs or parts: .... (specify the organs or parts).

SB655,17,7 .... I wish to donate any needed organ or part.

SB655,17,8 .... I wish to donate my body for anatomical study if needed.

SB655,17,11 .... 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.)

SB655,17,13 Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift.

SB655,17,14 Signature....     Date....

SB655,17,15 (End)