State of Wisconsin
Department of Health Services
Instructions to Complete the Power of Attorney for Health Care Form
To Whom It May Concern:
Enclosed is the Power of Attorney for Health Care form you requested. The Power of Attorney for Health Care form makes it
possible for adults in Wisconsin to authorize other individuals (called health care agents) to make health care decisions on their
behalf should they become incapacitated. It may also be used to make or refuse to make an anatomical gift (donation of all or
part of the human body to take effect upon the death of the donor).
Be sure to read all six (6) pages of the form carefully and understand it before you complete and sign it. Talk with those you
select as your health care agent and the alternate health care agent about your thoughts and beliefs about medical treatment.
Neither the health care agent nor the alternate may be your health care provider, an employee of a health care facility in which
you are a patient, or a spouse of any of those persons, unless he or she is also your relative.
Two witnesses are required. Witnesses must be at least 18 years of age, not related to you by blood, marriage, domestic
partnership, or adoption, and not directly financially responsible for your health care. A witness cannot be a health care provider
who is serving you at the time the document is signed or an employee of the health care provider unless the employee is a
chaplain or social worker. A witness cannot be an employee of an inpatient health care facility in which you are a patient, unless
the employee is a chaplain or social worker. A witness cannot be your health care agent nor have a claim on any portion of your
estate. Valid witnesses acting in good faith are immune from civil or criminal liability.
An original signed form may be kept on file with your physician or other primary care provider. A
signed Power of Attorney for
Health Care form may also be kept in a safe, easily accessible place until needed. You should make relatives and friends aware
that you have created a Power of Attorney for Health Care and the location where it is kept. Relatives and friends should also be
told whom you select as the health care agent and the alternate. The document may, but is not required to be, filed for
safekeeping, for a fee, with the Register in Probate of your county of residence. The fee for filing with the Register in Probate
has been set by State Statute at $8.00. A Power of Attorney for Health Care that is an original signed form or is a legible
photocopy or electronic facsimile copy is presumed to be valid. If you have both a Power of Attorney for Health Care and a
Declaration to Physicians, the provisions of a valid Power of Attorney for Health Care supersede any directly conflicting
provisions of a valid Declaration to Physicians.
One copy of the Power of Attorney for Health Care form is available free to anyone who sends a stamped, self-addressed,
business-size envelope to: Power of Attorney, Division of Public Health, P.O. Box 2659, Madison, Wisconsin 53701-2659. You
may make additional blank copies of the form you receive from the Division of Public Health. The form is also available on the
Department of Health Services Web page, https://www.dhs.wisconsin.gov/forms/advdirectives/index.htm.
Definitions ‘Department’ means the Department of Health Services. ‘Health Care’ means any care, treatment, service, or
procedure to maintain, diagnose, or treat an individual’s physical or mental condition. ‘Health care decision’ means an informed
decision in the exercise of the right to accept, maintain, discontinue, or refuse health care. ‘Health care facility’ means a facility,
as defined in State Statute 647.01(4), or any hospital, nursing home, community-based residential facility, county home, county
infirmary, county hospital, county mental health center, tuberculosis sanatorium or other place licensed or approved by the
department under State Statutes 49.70, 49.71, 49.72, 50.02, 50.03, 50.35, 51.08, 51.09, 58.06, 252.073 or 252.076 or a facility
under §§ 45.365, 51.05, 51.06, 233.40, 233.41. 233.42 or 252.10. ‘Health care provider’ means a nurse licensed or permitted
under State Statute Chapter 441, a chiropractor licensed under Chapter 446, a dentist licensed under Chapter 447, a physician,
podiatrist or physical therapist licensed or an occupational therapist or occupational therapy assistant certified under Chapter
448, a person practicing Christian Science treatment, an optometrist licensed under Chapter 449, a psychologist licensed under
Wisconsin.gov
F-00085
Chapter 455, a partnership thereof, a corporation thereof that provides health care services, an operational cooperative sickness
care plan organized under State Statute 185.981 to 185.985 that directly provides services through salaried employees in its own
facility, or a home health agency, as defined in State Statute 50.49 (1) (a). ‘Incapacity’ means the inability to receive and
evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage
his or her health care decisions. ‘Feeding tube’ means a medical tube through which nutrition or hydration is administered into
the vein, stomach, nose, mouth or other body opening of the declarant.
Who may sign a Power of Attorney for Health Care? An individual who is of sound mind and has attained age 18 may
voluntarily execute 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 State Statute Chapter 54 is presumed not to be of sound mind.
Procedure for signing a Power of Attorney for Health Care The principal (person creating the Power of Attorney for Health
Care) and the witnesses all must sign the form at the same time.
When does it take effect? Unless otherwise specified in the Power of Attorney for Health Care instrument (form), an
individual’s Power of Attorney for Health Care takes effect upon a finding of incapacity by 2 physicians, or a physician and a
psychologist, as defined in State Statute 448.01 (5), or nurse practitioner, or physician assistant who personally examine the
principal and sign a statement specifying that the principal has incapacity. Mere old age, eccentricity, or physical disability,
either singly or together, is insufficient to make a finding of incapacity. Neither of the individuals who make a finding of
incapacity may be a relative of the principal nor 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, shall be appended to the Power of Attorney for Health Care
instrument.
Revocation A princi
pal 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: 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; 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; verbally expressing the principal’s
intent to revoke the Power of Attorney for Health Care in the presence of 2 witnesses; or, executing a subsequent Power of
Attorney for Health Care instrument. 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.
Immunities 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: certifying incapacity under State Statute 155.05 (2), if the certification is made
in good faith based on a thorough examination of the principal; 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 physician to comply constitutes unprofessional conduct
if the physician refuses or fails to make a good faith attempt to transfer the principal to another physician who will comply;
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 Chapter 155; complying with the decision of a health care agent that is made under a
Power of Attorney for Health Care that is in compliance with Chapter 155; 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; or, 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. 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 Chapter 155. 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.
General provisions 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. 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. 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.
Important:
You must keep pages 1-6 of the form together as your executed document. Copies distributed
to health care providers, etc. must include pages 1 - 6.
F-00085
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-00085 (Rev. 02/2020)
STATE OF WISCONSIN Chapter 155.30(1),(3)
Effective Date February 7, 2020
608 266-1251
POWER OF ATTORNEY FOR HEALTH CARE DOCUMENT
NOTICE TO PERSON MAKING THIS DOCUMENT
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 may 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 unfamiliar 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 avoid 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 your 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 types 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 care
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 decisions 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 an
y time by 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, you should notify your agent,
health care provider(s), and any other person(s) to whom you have given a copy. If your agent is your
spouse or your domestic partner, and your marriage is annulled or you are divorced or your domestic
partnership is terminated after signing 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 gift, this document revokes any prior record 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 provision 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 or other primary care provider.
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Page 1 of 6
POWER OF ATTORNEY FOR HEALTH CARE
Document made this day of
(month), (year).
CREATION OF POWER OF ATTORNEY FOR HEALTH CARE
I,
(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. Despite 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 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 physical 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 make health care decisions for myself, due to my incapacity,
I hereby designate
(print 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
(print name, address and telephone number)
to be my alternate health care agent for the 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 care 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” exists if 2 physicians or a physician and a psychologist, nurse practitioner, or physician assistant
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 receive 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 document.
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Page 2 of 6
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 of 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 philosophy 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, due 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 proposed 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 choices 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 shall 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 basis to an institution for mental
diseases, an intermediate care facility for the persons with intellectual disability, a state treatment
facility, or a treatment facility. My health care agent may not consent to experimental mental health
research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures
for me.
ADMISSION TO NURSING HOMES
OR COMMUNITY-BASED RESIDENTIAL FACILITIES
My 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 health 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
2. A community-based residential facility Yes No
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 or respite care.
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PROVISION OF 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, physician assistant, or nurse practioner has advised that, 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 withdrawn 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 or 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 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 care 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 above, 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 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
any specific desires, provisions or limitations that I wish to state (add more items if needed):
1.
2.
3.
INSPECTION AND DISCLOSURE OF INFORMATION
RELATING TO MY PHYSICAL OR MENTAL HEALTH
Subject to any limitations in this document, my health care agent has the authority to do all of the following:
a) Request, review, and receive any information, oral or written, 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 disclosure of this information.
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(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 Date
(The signing of this document by the principal revokes all previous powers of attorney for health care
documents.)
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 attorney for health care is voluntary. I am at least 18 years of
age, am not related to the principal by blood, marriage, domestic partnership, or adoption, 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 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.
Witness Number 1
(Print) Name
Date
Address
Signature
Witness Number 2
(Print) Name
Date
Address
Signature
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Page 5 of 6
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
F-00085 (Rev. 02/2020)
F-00085
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