$17.95

Add to cart

Wisconsin __________________________________ Date ______________________ 7 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 _ody 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 notifye 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 bdecisions. Date: _______________ 6 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 donature 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 _____________________________________________ Alternate's signature ______________________________________________________ Address ________________________________________________________________ Fail__ (name of principal) has discussed his or her desires regarding health care decisions with me. Agent's signature _________________________________________________________ Address ___________________r 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. ______________________________________Witness Signature) STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT I understand that __________________________________________________ (name of principal) has designated me to be his oWitness Signature) Date: _______________ Witness No. 2: Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (t have a claim on the principal's estate. Witness No. 1: Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (in 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 no 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 chaplay for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health 5 cuments.) 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 attorne___________________________________________________ Date _____________________________________ (The signing of this document by the principal revokes all previous powers of attorney for health care doclosure of this information. (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.. _ 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 disto any limitations in this document, my health care agent has the authority to do all of the following (pursuant to Section 155.30(3): (a) Request, review and receive any information, oral or written,_______________________________________ _____________________________________________________________________ INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH Subject ___________________________ 2) ___________________________________________________________________ _____________________________________________________________________ 3) ____________________________esires, provisions or limitations that I wish to state (add more items if needed): 1) ___________________________________________________________________ 4 __________________________________________his 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 dove, 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 te 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 ab 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 carr 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 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 o 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 withdrawnor respite care. PROVISION OF A 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,2. A community-based residential facility Yes . No 3 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 h 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 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 healtental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me. ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES Myasis to an institution for mental diseases, an intermediate care facility for the mentally retarded, a state treatment facility or a treatment facility. My health care agent may not consent to experimhall 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 bchoices 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 sosed 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 e 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 propophy 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, duof 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 philosocument. 2 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 eive 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 d 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 recre 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" existsthe 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 ca______________________________________________________ ____________________________________________________________ (print name, address and telephone number) to be my alternate health care agent for int 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 _ake health care decisions for myself, due to my incapacity, I hereby designate. _______________________________________________________ ____________________________________________________________ (prsical 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 m 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 phyDespite 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 (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. th Care Document made this ____________________ day of _________ (month), _________ (year). CREATION OF POWER OF ATTORNEY FOR HEALTH CARE I, ___________________________________________________________N 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." 1 Power Of Attorney for HealGIFT, THIS DOCUMENT REVOKES ANY PRIOR DOCUMENT 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 PROVISIOG 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 YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNINY 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, CISIONS 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 BE 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 DEPES 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 CARYOUR 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 TY 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 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 AVOIDAY 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 UNFAMILIARTO PERSON MAKING THIS POWER OF ATTORNEY FOR HEALTH CARE 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 Marising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 6 NOTICE onsulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences nd are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without c is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended aa 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. [_] These forms are provided "as 51.15, for involuntary commitment under s. 51.20, or for protective placement or protective services under ch. 55. (d) Any person under the order of a court for good cause shown. (3) Failure to file ) A health care provider who is providing care to the principal. (c) The court and all parties involved in proceedings for guardianship of the principal under ch. 880, for emergency detention under s.th care instrument as specified in sub. (1), the following persons may have access to the instrument without first obtaining consent from the principal: (a) The health care agent for the principal. (bare instrument, for safekeeping, with the register in probate of the county in which the principal resides. (2) If a principal or health care agent has filed the principal's power of attorney for heal care provider of the revocation. 5 155.65 Filing power of attorney instrument. (1) A principal or a principal's health care agent may, for a fee, file the principal's power of attorney for health cf 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 healthrincipal that he or she knows has a copy of the power of attorney for health care instrument. (4) The principal's health care provider shall, upon notification of revocation of the principal's power o 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 pre instrument, the marriage is annulled or divorce from the spouse is obtained, the power of attorney for health care is revoked and the power of attorney for health care instrument is invalid. (3) Ifs. (d) Executing a subsequent power of attorney for health care instrument. (2) If the health care agent is the principal's spouse and, subsequent to the execution of a power of attorney for health cang the principal's intent to revoke the power of attorney for health care. (c) Verbally expressing the principal's intent to revoke the power of attorney for health care, in the presence of 2 witnesseting another in the presence of the principal to so destroy the power of attorney for health care instrument. (b) Executing a statement, in writing, that is signed and dated by the principal, expressilth care instrument at any time by doing any of the following: (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying the power of attorney for health care instrument or direc make that anatomical gift. 155.40 Revocation of power of attorney for health care. (1) A principal may revoke his or her power of attorney for health care and invalidate the power of attorney for heat. (8) A health care agent may make an anatomical gift under s. 157.06 (3) (a) 7. of all or a part of the principal's body after the principal's death unless the principal made an unrevoked refusal to authorized to make, in accordance with the desires of the principal, the health care agent may sign or otherwise execute any documents, waivers or releases related to the principal's care or treatmenealth care decision on behalf of the principal that the power of attorney for health care instrument authorizes. 4 (7) If necessary to implement the health care decisions that a health care agent is health care agent shall, in good faith, act in the best interests of the principal in exercising his or her authority. (6) If the principal is known to be pregnant, the health care agent may make a hnflicting provisions of a valid declaration executed by the principal under subch. II of ch. 154. In the absence of a specific directive by the principal or if the principal's desires are unknown, theith any valid declaration executed by the principal 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 coe power of attorney for health care instrument or as otherwise specifically directed by the principal to the health care agent at any time. The health care agent shall act in good faith consistently wdration unless provision of the nutrition or hydration is medically contraindicated. (5) The health care agent shall act in good faith consistently with the desires of the principal as expressed in th, the withholding or withdrawal will cause the principal pain or reduce the principal's comfort. A health care agent may not consent to the withholding or withdrawal of orally ingested nutrition or hyawal of a feeding tube for the principal if the power of attorney for health care instrument so authorizes, unless the principal's attending physician advises that, in his or her professional judgmentental health research or to psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for the principal. (4) A health care agent may consent to the withholding or withdrhorizes and if the principal is not diagnosed as developmentally disabled or as having a mental illness at the time of the proposed admission. (3) A health care agent may not consent to experimental m. c. To a nursing home or a community-based residential facility, for purposes other than those specified in subd. 2. a. and b., if the power of attorney for health care instrument specifically so autd residential facility, as a temporary placement not to exceed 30 days, in order to provide the health care agent with a vacation or to release temporarily the health care agent for a family emergencytted directly from a hospital inpatient unit, unless the hospital admission was for psychiatric care. b. If the principal lives with his or her health care agent, to a nursing home or a community-baset to the admission of a principal to the following facilities, under the following conditions: a. To a nursing home, for recuperative care for a period not to exceed 3 months, if the principal is admi) 1. In this paragraph: a. "Community-based residential facility" has the meaning given in s. 50.01 (1g). 3 b. "Nursing home" has the meaning given in s. 50.01 (3). 2. A health care agent may consen as defined in s. 51.01 (19). (b) A principal may be admitted or committed on an inpatient basis to a facility specified in par. (a) 1. to 4. only under the applicable requirements of ch. 51 or 55. (ced in s. 49.43 (6m). 2. An intermediate care facility for the mentally retarded, as defined in s. 46.278 (1m) (am). 3. A state treatment facility, as defined in s. 51.01 (15). 4. A treatment facility,ke these health care decisions. (2) (a) A health care agent may not consent to admission of the principal on an inpatient basis to any of the following: 1. An institution for mental diseases, as defin5.60 (2), the health care agent who is known to the health care provider to be available to make health care decisions for the principal has priority over any individual other than the principal to ma. 155.20 Health care agent; powers; limitations. (1) Unless the power of attorney for health care instrument otherwise provides and except as specified in subs. (2) (a) and (b), (3) and (4) and s. 15he principal or by an individual who has attained age 18, at the express direction and in the presence of the principal. (c) Signed in the presence of 2 witnesses who meet the requirements of sub. (2)10 Power of attorney for health care instrument; execution; witnesses. (1) A valid power of attorney for health care instrument shall be all of the following: (a) In writing. (b) Dated and signed by ttimes. (5) A principal may designate an alternate individual to serve as his or her health care agent in the event that the health care agent first designated is unable or unwilling to do so. 2 155.se of the provider or employee is a relative of the individual. (4) The desires of a principal who does not have incapacity supersede the effect of his or her power of attorney for health care at all an individual is a patient or resides, or a spouse of any of those providers or employees, may be designated by the individual as a health care agent unless the health care provider, employee or spouall be appended to the power of attorney for health care instrument. (3) No health care provider for an individual, employee of that health care provider or employee of a health care facility in whicha finding of incapacity may be a relative of the principal or 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, sh that the principal has incapacity. Mere old age, eccentricity or physical disability, either singly or together, are insufficient to make a finding of incapacity. Neither of the individuals who make capacity by 2 physicians, as defined in s. 448.01 (5), or one physician and one licensed psychologist, as defined in s. 455.01 (4), who personally examine the principal and sign a statement specifyingfor purposes of this subsection. (2) Unless otherwise specified in the power of attorney for health care instrument, an individual's power of attorney for health care takes effect upon a finding of in 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 ch. 880 is presumed not to be of sound mind r health care. (12) "Relative" has the meaning given in s. 242.01 (11). 155.05 Power of attorney for health care. (1) An individual who is of sound mind and has attained age 18 may voluntarily executeth care agent for the purpose of making health care decisions on his or her behalf if the individual cannot, due to incapacity. (11) "Principal" means an individual who executes a power of attorney fomunity to individuals aged 60 or older for purposes of the state plan under 42 USC 3027. (10) "Power of attorney for health care" means the designation, by an individual, of another as his or her healxtent that the individual lacks the capacity to manage his or her health care decisions. (9) "Multipurpose senior center" means a facility that is the focal point for the delivery of services in a comown facility, or a home health agency, as defined in s. 50.49 (1) (a). 1 (8) "Incapacity" means the inability to receive and evaluate information effectively or to communicate decisions to such an epany thereof that provides health care services, an operational cooperative sickness care plan organized under ss. 185.981 to 185.985 that directly provides services through salaried employees in its er ch. 448, a person practicing Christian Science treatment, an optometrist licensed under ch. 449, a psychologist licensed under ch. 455, a partnership thereof, a corporation or limited liability com under ch. 446, a dentist licensed under ch. 447, a physician, physician assistant, perfusionist, podiatrist, physical therapist, occupational therapist, or occupational therapy assistant licensed und.35, 51.08 or 51.09 or a facility under s. 45.365, 51.05, 51.06, 233.40, 233.41, 233.42 or 252.10. (7) "Health care provider" means a nurse licensed or permitted under ch. 441, a chiropractor licensedd residential facility, county home, county infirmary, county hospital, county mental health center or other place licensed or approved by the department under s. 49.70, 49.71, 49.72, 50.02, 50.03, 50he exercise of the right to accept, maintain, discontinue or refuse health care. (6) "Health care facility" means a facility, as defined in s. 647.01 (4), or any hospital, nursing home, community-baserincipal or, if that individual is unable or unwilling to make those decisions, an alternate individual designated by the principal to do so. (5) "Health care decision" means an informed decision in tdure to maintain, diagnose or treat an individual's physical or mental condition. (4) "Health care agent" means an individual designated by a principal to make health care decisions on behalf of the pedical tube through which nutrition or hydration is administered into the vein, stomach, nose, mouth or other body opening of a declarant. (3) "Health care" means any care, treatment, service or proce Statutes relating to the Power Of Attorney For Health Care Form. 155.01 Definitions. In this chapter: (1) "Department" means the department of health and family services. (2) "Feeding tube" means a mttorney For Health Care Form. This Wisconsin Power Of Attorney For Health Care is based on the Wisconsin Statutes Chapter 154. For your convenience, we have included useful excerpts from the WisconsinInformation and Instructions Wisconsin Power Of Attorney For Health Care This package contains (1) Information and Instruction for Wisconsin Power Of Attorney For Health Care; (2) Wisconsin Power Of A Wisconsin