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Wisconsin Medical Power of Attorney Form

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Wisconsin Medical Power of Attorney Form is documentation one must produce when representing an unconscious patient with medical professionals. Only the patient who has issued this document can define its instructions and grant the authority it grants to an agent or health care representative. Generally, such an agent is someone who the principal, or patient, feels comfortable with and has an ongoing rapport with (such as a spouse or a sibling). The powers or authority being granted to the agent will focus on decisions the principal patient wishes made regarding treatment during times when a medical event has rendered the patient with severely impaired judgment, unconscious, or otherwise unable communicate. One can be quite vulnerable at such times particularly when a questionable on nonstandard medical procedure must be employed. This document will provide a way for you to make sure that you have someone in place ready to make medical decisions for you when you have reached the point when you cannot make your own decisions. Many agree it is both reassuring and wise to have such an agent in place with the signed authority required to behave in the manner you decide.

Definition – § 155.01(10)

LawsChapter 155 (Power of Attorney for Health Care)

Living Will – Gives a directive to physicians if and when a patient should become in a persistent vegetative state.

Durable (Financial) Power of Attorney – Gives your agent the legal authority to act on your behalf in financial matters.

How to Write

1 – The PDF Document Here Should Be Saved To Your Computer

A Health Care Agent may be appointed with the required Principal Power to represent a Principal’s interests using the template provided here. You may acquire a workable PDF copy by selecting either the PDF button or the image above it. The Principal (and Agent) must read the disclosure at the start of this paperwork to be fully abreast of each one’s rights/responsibilities.

2 – Date This Paperwork

The first task set before us will be to identify the Calendar Date when you set your Medical Treatment Preferences on paper. Locate the first statement under this document’s title (“Power Of Attorney For Health Care”) to supply the Calendar Day, Month, and Year of this document. Enter this date with each component in its respective area using the DD/MONTH/YYYY format. 

3 – Fully Identify Yourself

If this paperwork is to be fully effective, you must make sure you identify yourself, so no doubt will be made as to the author. Supply your Full Name, Complete Address, and Date of Birth on the blank lines just beneath the heading “Creation Of Power Of Attorney For Health Care.”

4 – Formally Declare The Identity Of Your Health Care Agent

The next item that must be supplied is the Name of the person who you have elected to make Health Care Decisions on your behalf if/when you are incapacitated. Fill in this person’s Full Name and Address using the first blank area in the “Designation Of Health Care Agent” section. This paperwork will also give you the opportunity to automatically deliver the same Principal Powers you have appointed the Health Care Agent above to another individual but only if the Health Care Agent above cannot or will not carry out your Health Care Directives. This backup Agent is often referred to as a Successor Health Care Agent or Alternate Health Care Agent. If you wish to set up an Alternate Agent through this document (recommended) then record his or her Name and Address on the second set of blank lines in this section.

5 – Your Preferences Regarding Medical Care Should Be Clearly Reported

Once you have read the text in the “General Statement Of Authority Granted,” you will have the chance to adjust the Principal Powers you wish to deliver to the Health Care Agent. Begin by addressing the issues in “Admission To Nursing Home Or Community-Based Residential Facilities.” Here, indicate if the Health Care Agent has the Principal Power to admit you to a Nursing Home or Community-Based Residential Facility, regardless of whether recuperative or respite care is required. Items 1 and 2 (respectively) will each be accompanied by a “Yes” and “No” checkbox. To allow the Health Care Agent the Principal Power to take such actions then mark the “Yes” box. If not, then mark the “No” box.  Next, the “Provision Of Feeding Tube” section will present the scenario of you requiring artificial nourishment (through tubes). If you would like the Health Care Agent to provide your acceptance of this treatment, then mark the “Yes” box. If you do not wish the Health Care Agent to have this Power, then mark the “No” checkbox. The “Health Care Decisions For Pregnant Women” should be read through if you are female with the possibility of becoming pregnant. If the Health Care Agent can continue to make Health Care decisions on your behalf if you are known to be pregnant, then mark the “Yes” box. If you do not want the Health Care Agent to have such decision-making Powers when you are pregnant then, mark the “No” box. If you are male, you may ignore this section. The “Statement Of Desires, Special Provisions, Or Limitations” segment of this document will contain three numbered lines, though you may add as many as you like or continue on an attachment if this is not enough room. This section will apply your specific concerns and wishes to the Powers being delivered. Here you may forbid the Agent from taking certain actions, insist upon certain considerations to satisfy any religious beliefs you have, adjust the time period when these Powers are effective, and describe your Medical Treatment preferences in various scenarios. Any and all such provisions should be documented in this section and must be done so before you execute this form through the act of signing it.

6 – An Execution Signature Before Two Witnesses Is Required

The “Signature Of Principal” section will be where you finally execute this delegation of Principal Powers to the Health Care Agent by signing this paperwork. Locate the blank line “Signature” then sign it. Make sure to record the current Calendar Date on the adjacent “Date” line. This act must occur before two Witnesses, so when you have successfully supplied these items, release the document to the Witnessing parties. Each Witness must read the “Statement Of Witnesses” section then Print his or her Name, supply the Current Date, supply his or her Address, and sign his or her Name. There will be two areas (“Witness Number 1″ and Witness Number 2”) so that each one will have his or her own set of lines to provide these items.

7 – The Pre-determined Health Care Agent Must Attend To A Statement

Some minor preparation will be required for the “Statement Of Health Care Agent And Alternate Health Care Agent” section. Locate the two blank lines in the statement here then print the Name of the Principal (the person giving Principal Power) on them. The Health Care Agent and Alternate Health Care Agent should each provide his or her Signature and Address in the area provided.

8 – You Reserve The Option To Make A Statement Regarding Anatomical Gifts

The final portion of this paperwork “Anatomical Gifts” is optional but is recommended for most cases. Here you can specifically deliver your expectations regarding anatomical gifts. Four checkbox statements have been presented in this section for a quick and easy method to document your preferences. For instance, if you would like to make Anatomical Gifts, but wish to only donate certain body parts, then mark the checkbox statement “I wish To Donate Only The Following….” then, list the Anatomical Gifts you will allow. If you would like to Donate any organ or body part, then mark the second checkbox. Should you wish to make Anatomical Gifts for study, then mark the third checkbox. Mark the fourth checkbox only if you do not wish to make any kind of Anatomical Gift or donate any organs. If you have completed this section, you must Sign your name on the Signature line here and supply a Date of Signature. Note: Anything reported here will automatically revoke previous Anatomical Gifts Statements you have made.


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