This required section states the basic purpose for this document. It is important for the Principal to understand the rights and duties of all parties before executing this document. Press [Ctrl+F1] for more information.
This required section creates a Power of Attorney for Health Care. It shall be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Agent. Press [Ctrl+F1] for information.
This is a required section concerning the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section describes limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This required section states that the Agent may admit the Principal to a nursing home for short-term stays or respite care. Press [Ctrl+F1] for more information.
This required section states whether artificially administered nutrition and fluids may be withdrawn or withheld in described circumstances. Press [Ctrl+F1] for more information.
This optional section enables the Principal to choose whether or not the Agent will be able to make health care decisions for the Principal in the event that the Principal is pregnant. Press [Ctrl+F1] for information.
This required section gives the Principal the opportunity to include special provisions or limits concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
This required section enables the Agent to request, review and disclose information regarding the physical and mental condition of the Principal. Press [Ctrl+F1] for more information.
By signing this required section, the Principal will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses. The witness statement describes limits on who may act as a witness. Press [Ctrl+F1] for more information.
This section requires the signature of the Agent to acknowledge the designation as Agent and that the Principal has expressed his/her desires regarding health care to the Agent. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
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Health Care POA
HCP_WI
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
!! !
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter an X to include the name of an Alternate Agent. If the original Agent resigns or is unable to perform, an Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Principal's spouse as Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter an X to include the name of a Second Alternate Agent. You do not have to name a Second Alternate Agent.
HWI01
! Disclosure Statement Section (1 of 14)
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 IT, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.
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.
It is important that this section be read in order to understand the purpose of this document, and the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions (the "Agent").
HWI02
! Creation of Power of Attorney for Health Care Section (2 of 14)
POWER OF ATTORNEY FOR HEALTH CARE
Document made this _____ day of _______________, 19___.
!. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE.
I, !, of
!, ! !,
! Country: !,
Birthdate: !,
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.
This required section states that a Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Principal's street address or edit the information as desired.
Enter the Principal's extended street address or edit the information as desired.
Enter the Principal's city or edit the information as desired.
This is a state-specific document. Enter the Principal's state or edit the information as desired. In most cases, the Principal's state will be Wisconsin.
Enter the Principal's zip/postal code or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the Principal's date of birth or edit the information as desired.
HWI03
! Designation of Health Care Agent Section (3 of 14)
!. 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
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
to be my Health Care Agent for the purpose of making health care decisions on my behalf.
! [Optional]
If he or she is ever unable or unwilling to do so, I hereby designate
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
! SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
to be my Alternate Health Care Agent for the purpose of making health care decisions on my behalf.
Neither my Health Care Agent or 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 two physicians or a physician and a psychologist 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.
This required designation section states the name and address of the person appointed as Health Care Agent. The Agent will make health care decisions for the Principal if the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the Agent's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear later in this section. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired. When naming an Agent, consider the availability of the Agent to confer with health care providers and access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
Enter an X to include the name of an Alternate Agent. If the original Agent resigns or is unable to perform, an Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Principal's spouse as Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter an X to include the name of a Second Alternate Agent. You do not have to name a Second Alternate Agent.
HWI04
! Authority of Agent Section (4 of 14)
!. 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 so 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.
This required section states the general duties and powers the Agent is responsible for on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HWI05
! Limitations on Agent Section (5 of 14)
!. 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 mentally retarded, 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.
This required section describes limitations on the authority given to the Agent. For example, the Agent may not authorize certain types of treatment. Press [Ctrl+F1] for more information.
HWI06
! Nursing Homes Section (6 of 14)
!. 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:
Yes No
a. A nursing home
! (X) Yes ( ) No
! ( ) Yes (X) No
b. A community-based residential facility
! (X) Yes ( ) No
! ( ) Yes (X) No
[The program requires that a selection be made although the language of Wisconsin's form provides for a contingency if no selection is made.]
If I have not checked either "Yes" or "No" immediately above, my Health Care Agent may only admit me for short-term stays for recuperative care or respite care.
This required section enables the Principal to express his/her desires concerning admission to a nursing home or community-based residential facility. Press [Ctrl+F1] for more information.
Enter an X if the Agent MAY admit the Principal to a nursing home for a purpose other than recuperative care or respite care.
Enter an X if the Agent MAY NOT admit the Principal to a nursing home for a purpose other than recuperative care or respite care.
Enter an X if the Agent MAY admit the Principal to a community based residential facility for a purpose other than recuperative care or respite care.
Enter an X if the Agent MAY NOT admit the Principal to a community based residential facility for a purpose other than recuperative care or respite care.
HWI07
! Nutrition and Hydration Section (7 of 14)
!. PROVISION OF A 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 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.
Yes No
Withhold or withdraw a feeding tube.
! (X) Yes ( ) No
! ( ) Yes (X) 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.
This required section concerns artificially administered nutrition and hydration (fluids). Press [Ctrl+F1] for more information.
Enter an X if non-orally ingested (artificially administered) nutrition and hydration SHALL be withheld or withdrawn in the described circumstances. Press [Ctrl+F1] for more information.
Enter an X if non-orally ingested (artificially administered) nutrition and hydration SHALL NOT be withheld or withdrawn in the described circumstances.
HWI08
! Optional Pregnancy Provisions Section (8 of 14)
!. 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.
Yes No
Health care decision if I am pregnant
! (X) Yes ( ) No
! ( ) Yes (X) 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.
Enter an X to include a section that allows the Principal to state whether the Agent will have the authority to make health care decisions for the Principal when the Principal is pregnant. This section should be included if the Principal is female.
Enter an X if the Agent WILL have the authority to make health care decisions for the Principal if the Principal is pregnant, and unable to make health care decisions for herself.
Enter an X if the Agent WILL NOT be given the authority to make health care decisions for the Principal if the Principal is pregnant, and unable to make health care decisions for herself.
HWI09
! Desires, Special Provisions and Limitations Section (9 of 14)
!. 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):
A. ! ! ! ! !
B. ! ! ! ! !
C. ! ! ! ! !
This required section allows the Principal to state special provisions concerning health care which are not otherwise contained in the document. For example, specify any types of treatment you wish or wish not to receive, or state any limitations on the authority of the Agent. Press [Ctrl+F1] for more information.
Use this space to include special provisions, desires, or limitations regarding health care, or your Agent's authority to make decisions for you. Access Document Information for sample provisions.
Use this space, if needed, to include a second paragraph of special provisions, desires, or limitations regarding health care, or your Agent's authority to make decisions.
Use this space, if needed, to include a third paragraph of special provisions, desires, or limitations regarding health care, or your Agent's authority to make decisions.
HWI10
! Inspection and Disclosure of Information Section (10 of 14)
!. 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, verbal 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.
This required section enables the Agent to request, review, and disclose any information regarding the physical or mental condition of the Principal. Press [Ctrl+F1] for more information.
HWI11
! Signature Section (11 of 14)
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)
(THE SIGNING OF THIS DOCUMENT BY THE PRINCIPAL REVOKES ALL PREVIOUS POWERS OF ATTORNEY FOR HEALTH CARE DOCUMENTS.)
This section requires the signature of the Principal in the presence of two witnesses. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
HWI12
! Witness Signature Section (12 of 14)
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, and am not related to the Principal by blood, marriage 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 Principal 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.
This section requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HWI13
! Statement of Health Care Agent Section (13 of 14)
[The Agent (and any Alternate Agents) must sign the document to indicate acceptance of their appointment.]
STATEMENT OF HEALTH CARE AGENT AND
ALTERNATE HEALTH CARE AGENT
I understand that ! 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. ! has discussed his or her desires regarding health care decisions with me.
In this required section, the Agent and Alternate Agent(s) agree and understand that they have been designated to be the health care Agent(s) for the Principal. Desires of the Principal have been fully explained to the Agent(s) to better enable the Agent to make health care decisions on the Principal's behalf.
DOM01
! Health Care Document Information Section (14 of 14)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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