Power of Attorney Form for Health Care - Wisconsin

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 s. 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 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 880 is presumed not to be of sound mind.
Procedures 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, as defined in State Statute 448.01 (5), or one physician and one licensed
psychologist, as defined in State Statute.455.01 (4), 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 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: 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.
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