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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.
