(print) Name.... Date....
Address....
Signature....
Witness No. 2:
(print) Name.... Date....
Address....
Signature....
STATEMENT OF HEALTH CARE AGENT AND
ALTERNATE HEALTH CARE AGENT
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.
Agent’s signature....
Address....
Alternate’s signature....
Address....
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....
155.30 AnnotationSub. (1) merely sets out standard language that must be included on health care power of attorney (HCPOA) forms that are distributed or sold in Wisconsin for use by persons who lack legal counsel. That language serves informative and instructive functions. It does not define “health care decisions” in terms of the right to demand any health care that the patient desires. Nothing in the plain language of sub. (1) or the definition of a health care decision under s. 155.01 (5) requires a health care provider to act on a HCPOA’s requests or demands for specific treatment that is below the standard of care. Gahl ex rel. Zingsheim v. Aurora Health Care, Inc., 2022 WI App 29, 403 Wis. 2d 539, 977 N.W.2d 756, 21-1787. 155.40155.40 Revocation of power of attorney for health care. 155.40(1)(1) 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: 155.40(1)(a)(a) 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. 155.40(1)(b)(b) 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. 155.40(1)(c)(c) Verbally expressing the principal’s intent to revoke the power of attorney for health care, in the presence of 2 witnesses. 155.40(1)(d)(d) Executing a subsequent power of attorney for health care instrument. 155.40(2)(2) If the health care agent is the principal’s spouse or domestic partner under ch. 770 and, subsequent to the execution of a power of attorney for health care instrument, the marriage is annulled or divorce from the spouse is obtained or the domestic partnership under ch. 770 is terminated, the power of attorney for health care is revoked and the power of attorney for health care instrument is invalid. 155.40(2m)(2m) If a principal, after executing a power of attorney for health care, is adjudicated incompetent in this state, the power of attorney for health care remains in effect, except that a court may under s. 54.46 (2) (b), for good cause shown, revoke the power of attorney for health care and invalidate the power of attorney for health care instrument, or limit the authority of the agent under the terms of the power of attorney for health care instrument. 155.40(3)(3) If an individual knows that the power of attorney for health care that named him or her as health care agent has been revoked, he or she shall communicate this fact to any health care provider for the principal that he or she knows has a copy of the power of attorney for health care instrument. 155.40(4)(4) 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. 155.50155.50 Duties and immunities. 155.50(1)(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: 155.50(1)(a)(a) Certifying incapacity under s. 155.05 (2), if the certification is made in good faith based on a thorough examination of the principal. 155.50(1)(b)(b) 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 health care professional, as defined in s. 154.01 (3), to comply constitutes unprofessional conduct if the health care professional refuses or fails to make a good faith attempt to transfer the principal to another health care professional who will comply. 155.50(1)(c)(c) 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 this chapter or the decision of a health care agent that is made under a power of attorney for health care that is in compliance with this chapter. 155.50(1)(d)(d) 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. 155.50(1)(e)(e) 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. 155.50(2)(2) In the absence of actual notice to the contrary, a health care facility or health care provider may presume that a principal was authorized to execute the principal’s power of attorney for health care under the requirements of this chapter and that the power of attorney for health care instrument is valid. 155.50(3)(3) 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 this chapter. 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. 155.50(4)(4) Subsections (1), (2), and (3) apply to acts or omissions in connection with a provision of a power of attorney for health care that is executed in another jurisdiction if the provision is valid and enforceable under s. 155.70 (10). 155.60(1)(1) Nothing in this chapter prohibits an individual from petitioning a court in this state for a determination of incompetency and for appointment of a guardian for an individual who is a principal under this chapter. 155.60(2)(2) If an individual who is a principal is adjudicated incompetent in this state and a guardian is appointed for him or her, the power of attorney for health care executed under this chapter by the principal remains in effect, except that the court may under s. 54.46 (2) (b), for good cause shown, revoke the power of attorney for health care and invalidate the power of attorney for health care instrument, or limit the authority of the agent under the terms of the power of the power of attorney for health care instrument. Unless the court makes this revocation or limitation, the guardian for the individual may not make health care decisions for the ward that may be made by the health care agent, unless the guardian is the health care agent. 155.60(3)(3) Upon receipt of a power of attorney for health care instrument or a statement of incapacity under s. 155.05 (2), a health care facility or health care provider shall acknowledge this receipt in writing and, if the principal is a patient of the health care provider, the health care provider shall include the instrument or the statement in the medical record of the principal. 155.60(4)(a)(a) Any interested party may petition the court assigned to exercise probate jurisdiction for the county where a principal is present or the county of the principal’s legal residence to review whether the health care agent is performing his or her duties in accordance with the terms of the power of attorney for health care instrument executed by the principal. If the court finds after a hearing that the health care agent has not been performing in accordance with the terms of the instrument, the court may do any of the following: 155.60(4)(a)1.1. Direct the health care agent to act in accordance with the terms of the principal’s power of attorney for health care instrument. 155.60(4)(a)2.2. Require the health care agent to report to the court concerning performance of the health care agent’s duties at periods of time established by the court. 155.60(4)(a)3.3. Rescind all powers of the health care agent to act under the power of attorney for health care and the power of attorney for health care instrument. 155.60(4)(b)(b) If the principal has designated an alternate health care agent and if the powers of the first-designated health care agent are rescinded under par. (a) 3., the alternate health care agent is the health care agent and par. (a), except par. (a) 3., applies. 155.60 HistoryHistory: 1989 a. 200; 2005 a. 387. 155.65155.65 Filing power of attorney instrument. 155.65(1)(1) A principal or a principal’s health care agent may, for a fee, file the principal’s power of attorney for health care instrument, for safekeeping, with the register in probate of the county in which the principal resides. 155.65(2)(2) If a principal or health care agent has filed the principal’s power of attorney for health care instrument as specified in sub. (1), the following persons may have access to the instrument without first obtaining consent from the principal: 155.65(2)(b)(b) A health care provider who is providing care to the principal. 155.65(2)(c)(c) The court and all parties involved in proceedings in this state for adjudication of incompetency and appointment of a guardian for the principal, for emergency detention under s. 51.15, for involuntary commitment under s. 51.20, or for protective placement or protective services under ch. 55. 155.65(2)(d)(d) Any person under the order of a court for good cause shown. 155.65(3)(3) Failure to file a power of attorney for health care instrument under sub. (1) creates no presumption about the intent of an individual with regard to his or her health care decisions. 155.65 HistoryHistory: 1991 a. 281; 2005 a. 387. 155.70155.70 General provisions. 155.70(1)(a)(a) 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. Execution of a power of attorney for health care instrument under this chapter does not, for any purpose, constitute attempted suicide. 155.70(1)(b)(b) Paragraph (a) does not prohibit an insurer from making a determination that a principal has attempted suicide or committed suicide based on the principal’s action to do so, apart from the power of attorney for health care instrument. 155.70(2)(2) 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. The designation by a principal of a health care agent under a power of attorney for health care instrument is not a bar to the receipt of health care or admission to a health care facility. 155.70(3)(3) This chapter does not apply to the provisions of a valid declaration executed under subch. II of ch. 154, except that the provisions of a principal’s valid power of attorney for health care instrument supersede any directly conflicting provisions of a valid declaration executed under subch. II of ch. 154 for a declarant who is that principal. 155.70(4)(a)(a) Nothing in this chapter may be construed to render invalid a durable power of attorney that is executed under s. 243.07, 2007 stats., prior to April 28, 1990. 155.70(4)(b)(b) A health care decision made under the authority of a durable power of attorney specified in par. (a) is valid. 155.70(5)(5) 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. 155.70(6)(6) A power of attorney for health care instrument that is in its original form or is a legible photocopy or electronic facsimile copy is presumed to be valid. 155.70(7)(7) Nothing in this chapter may be construed to condone, authorize, approve or permit any affirmative or deliberate act to end life other than the withholding or withdrawing of health care under a power of attorney for health care so as to permit the natural process of dying. In making health care decisions under a power of attorney for health care, an attempted suicide by the principal may not be construed to indicate a desire of the principal that health care treatment be restricted or inhibited. 155.70(8)(8) Failure to execute a power of attorney for health care document under this chapter creates no presumption about the intent of any individual with regard to his or her health care decisions. 155.70(9)(9) A power of attorney for health care instrument under s. 155.30 (1), 1989 stats., that is executed before, on or after May 14, 1992, and that is not subsequently revoked is governed by the provisions of ch. 155, 1989 stats. 155.70(10)(10) A valid document granting a health care agent authority to make health care decisions for a principal that is executed in another state or jurisdiction in compliance with the law of that state or jurisdiction is valid and enforceable in this state to the extent that the document authorizes the health care agent to make decisions for the principal that a health care agent may make for a principal under this chapter. 155.80(1)(1) Whoever directly or indirectly coerces, threatens or intimidates an individual so as to cause the individual to execute a power of attorney for health care instrument shall be fined not more than $500 or imprisoned for not more than 30 days or both. 155.80(2)(2) Whoever intentionally conceals, cancels, defaces, obliterates, damages or destroys a power of attorney for health care instrument without the consent of the principal for that instrument may be fined not more than $500 or imprisoned for not more than 30 days or both. 155.80(3)(3) Whoever knowingly conceals, falsifies or forges a power of attorney for health care instrument with intent to create the false impression that a person other than the health care agent has been so designated shall be fined not more than $1,000 or imprisoned for not more than 9 months or both. 155.80(4)(4) Whoever intentionally withholds actual knowledge of the revocation of a power of attorney for health care or of the falsification or forgery of a power of attorney for health care instrument shall be fined not more than $1,000 or imprisoned for not more than 9 months or both.
