Power of Attorney Form for Health Care - Wisconsin

DIVISION OF PUBLIC HEALTH
1 WEST WILSON STREET
P O BOX 2659
Scott Walker MADISON WI 53701-2659
Governor
State of Wisconsin 608-266-1251
Kitty Rhoades FAX: 608-267-2832
Secretary TTY: 888-701-1253
Department of Health Services dhs.wisconsin.gov
Wisconsin.gov
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 or 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. 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. If you have any questions about the
availability of the Power of Attorney for Health Care form or obtaining larger quantities of the form, you
may contact the Division of Public Health by telephoning 608-266-1251.
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