Wisconsin Medical Power of Attorney Form

The Wisconsin medical power of attorney form legally permits an appointed person, who can be referred to as an `Agent, to make medical welfare decisions on the principal`s behalf should they become  unable to do so themselves through serious illness such as a coma or mental impairment. The document requires two witnesses. The document is in accordance with the US Statutes §155.01 to .80.

How to Write

Power Of Attorney For Health Care

The principal`s details must be entered.

  • Date.
  • Principal`s name.
  • Principal`s address.
  • Principal`s date of birth.

 

Agent

The agent`s and alternative agent`s details must be entered.

  • Agent`s name.
  • Agent`s address.
  • Agent`s telephone number.

 

Admission To Medical Facility

The principal must indicate their wishes regarding being admitted to a medical care facility.

  • Check box `Yes` to be admitted to a nursing home.
  • Check box `No` to be admitted to a nursing home.
  • Check box `Yes` to be admitted to a community residential facility.
  • Check box `No` to be admitted to a community residential facility.

 

Provision Of Feeding Tube

The principal must indicate their wishes regarding the use of a feeding tube.

  • Check box `Yes` to withdraw or withhold use of a feeding tube.
  • Check box `No` not to withdraw or withhold use of a feeding tube/

 

Decisions During Pregnancy

The principal must indicate their wishes regarding the agent`s authority to make health care decisions if they are pregnant.

  • Check box `Yes` to allow agent to make health care decisions.
  • Check box `No` not to allow agent to make health care decisions.

 

Statement Of Desires, Special Provisions Or Limitations

The principal may enter specific details of any desires, provisions or limitations regarding their medical health care.

 

Signatures

The principal, witnesses and agent`s will enter their details.

  • Principal`s signature.
  • Date.
  • Witnesses name.
  • Witnesses address.
  • Witnesses signatures.
  • Date.
  • Principal`s name.
  • Principal`s name.
  • Agent`s signature.
  • Agent`s address.

 

Anatomical Gift

The principal must check the relevant box and enter details if required to indicate their wishes regarding the making of an anatomical gift after their death.

  • Check box to donate specifically named organs and body parts.
  • Check box to donate any required organs and body parts.
  • Check box to donate body for anatomical study of required.
  • Check box to refuse to make an anatomical gift.
  • Principals signature.
  • Date.