Power of Attorney Form for Health Care - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-00085 (Rev. 06/11)
STATE OF WISCONSIN
Chapter 155.30(1),(3)
Effective Date August 3, 2009
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 any 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.
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