Fillable Medical Power of Attorney Document for Wisconsin State

The Wisconsin Medical Power of Attorney form is a legal document designed to allow individuals to appoint someone they trust to make healthcare decisions on their behalf, should they become unable to do so themselves. This important form ensures that a person's healthcare preferences are respected and adhered to by medical professionals, even when they are unable to communicate. To ensure your wishes are honored, consider filling out a Wisconsin Medical Power of Attorney form by clicking the button below.

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Imagine a situation where, due to unforeseen medical circumstances, a person becomes unable to make decisions about their own healthcare. This is where the Wisconsin Medical Power of Attorney form plays a crucial role. It acts as a legal document that allows individuals to appoint someone they trust, known as a healthcare agent, to make healthcare decisions on their behalf if they are unable to do so themselves. This form encompasses decisions ranging from routine medical care to critical life-support measures. Its significance cannot be overstated, as it provides peace of mind for the person, knowing their healthcare preferences are in trusted hands, and also eases the decision-making burden on family members during stressful times. Understanding and completing the Wisconsin Medical Power of Attorney form is therefore a vital step in healthcare planning, offering clarity and guidance for both healthcare providers and loved ones in the face of uncertainty.

Contents

Wisconsin Medical Power of Attorney Example

Wisconsin Medical Power of Attorney

This Wisconsin Medical Power of Attorney is a legal document that allows you, the Principal, to designate an individual, known as the Agent, to make healthcare decisions on your behalf should you become unable to do so. This document complies with the Wisconsin Statutes, specifically the sections within Chapter 155 - Power of Attorney for Health Care.

Please provide the necessary information in the spaces provided to complete this document.

Principal Information

Full Name: ___________________________

Address: _____________________________

City: ________________________________

State: WI

Zip Code: ____________________________

Date of Birth: ________________________

Agent Information

Full Name of Agent: _____________________________

Relationship to Principal: ________________________

Address: ________________________________________

City: ___________________________________________

State: WI

Zip Code: ______________________________________

Primary Phone Number: ___________________________

Alternate Phone Number: _________________________

Alternate Agent Information (Optional)

In the event that my primary agent is unable, unwilling, or unavailable to act as my agent, I appoint the following person as my alternate agent.

Full Name of Alternate Agent: _________________________

Relationship to Principal: ____________________________

Address: __________________________________________

City: _____________________________________________

State: WI

Zip Code: ________________________________________

Primary Phone Number: _____________________________

Alternate Phone Number: ___________________________

Health Care Decisions

My agent is authorized to make all decisions regarding my health care, including decisions about refusing or consenting to treatment, services, and procedures. This authorization includes, but is not limited to, decisions regarding admitting or discharging me from any hospital, nursing home, or other medical care facility.

Special Instructions

Use the space below to provide any specific limitations you wish to place on your agent's authority to make health care decisions for you. If you have none, you can leave this section blank.

______________________________________________________________________________

Signatures

This document must be signed in the presence of two witnesses, neither of whom is the person appointed as agent or alternate agent.

Principal's Signature: ___________________________ Date: ______________

Print Name: _____________________________________

Witnesses

Witness #1 Signature: _________________________ Date: ___________

Print Name: __________________________________
Witness #2 Signature: _________________________ Date: ___________

Print Name: __________________________________

Acceptance of Appointment

I, ___________________________________, hereby accept the appointment as an agent to make health care decisions for the above-named principal. I understand my responsibilities, and I will act in accordance with the principal's desires as stated in this document or as otherwise known to me.

Agent's Signature: ___________________________ Date: ______________

Print Name: _____________________________________

If an alternate agent has been named and has agreed to serve, they must sign below.

I, ___________________________________, hereby accept the appointment as an alternate agent to make health care decisions for the above-named principal, should the primary agent be unable. I understand my responsibilities and will act in accordance with the principal's desires as stated in this document or as otherwise known to me.

Alternate Agent's Signature: ___________________________ Date: ______________

Print Name: ___________________________________________

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Form Overview

Fact Number	Fact Detail
1	In Wisconsin, the Medical Power of Attorney form is officially known as the Power of Attorney for Health Care form.
2	This form allows a person, known as the principal, to appoint someone else, referred to as the agent, to make health care decisions on their behalf if they become unable to do so.
3	The agent's decision-making power activates when a physician determines that the principal is no longer able to make their own health care decisions.
4	Under Wisconsin law, specifically Wisconsin Statutes § 155.10, the form must be signed in the presence of two witnesses or a notary public to be legally binding.
5	Witnesses to the form cannot be anyone who is financially responsible for the principal's medical care, a health care provider, or an employee of a health care provider currently treating the principal.
6	The form allows the principal to specify preferences for medical treatments and life-sustaining measures, ensuring that their wishes are followed.
7	Principals can also appoint an alternate agent in the form, who can step in if the initial agent is unable or unwilling to act.
8	If there are disagreements among family members or between the family and the agent regarding the principal's care, the agent's decision takes precedence as per the authority granted through the form.
9	The form does not expire unless a specific date of expiration is noted within it, ensuring long-term validity unless the principal decides to revoke or update it.
10	To revoke the Power of Attorney for Health Care, the principal must inform the agent in writing or by physically destroying the document in a way that shows intent to cancel it.

Documents used along the form

When preparing for future healthcare decisions, it's important to consider all necessary legal documents that complement the Wisconsin Medical Power of Attorney. This particular form allows you to appoint someone to make healthcare decisions on your behalf should you become unable to do so. However, its full effectiveness often relies on the presence of additional documents, each serving its own unique purpose in safeguarding your health and legal rights.

Advance Directive: Outlines your preferences for medical treatment and end-of-life care, guiding healthcare providers when you're not in a position to communicate your wishes.
Living Will: Specifies the types of life-sustaining treatments you would or would not want if you're terminally ill or permanently unconscious.
Do Not Resuscitate (DNR) Order: Instructs medical personnel not to perform CPR if your breathing or heartbeat stops.
Declaration to Physicians (Wisconsin Living Will): A state-specific form that details your wishes regarding life-sustaining measures.
Health Insurance Portability and Accountability Act (HIPAA) Release Form: Allows designated individuals to access your medical records, facilitating better-informed decisions about your care.
Durable Power of Attorney for Finances: Designates someone to manage your financial affairs if you're unable to do so, ensuring that your finances are in order while you're incapacitated.
Organ Donor Registry Form: Records your decision to donate your organs and tissues upon death, potentially saving lives.
Funeral Directive: Lets you specify details about your funeral arrangements, relieving your loved ones of the burden of making those decisions during a difficult time.

Together, these documents form a comprehensive legal framework to protect your health care and personal wishes. It's advisable to discuss your options with a legal professional to ensure that your documents are properly executed and reflect your current wishes. Preparing these documents in advance provides peace of mind to both you and your loved ones, knowing that your healthcare and personal matters will be handled according to your preferences.

Consider Some Other Medical Power of Attorney Templates for Specific States

Illinois Poa Healthcare - It’s a key component of advance healthcare directives, complementing living wills by appointing a decision-maker for your medical care.

Maryland Power of Attorney Form - Discussing your choice of agent and your healthcare wishes with that individual is essential for ensuring your intentions are clearly understood.

Colorado Medical Power of Attorney Requirements - By selecting a health care agent through this form, you can have peace of mind knowing your medical choices are in good hands.

Medical Power of Attorney Missouri - An effective way to ensure continuity in your healthcare, the form facilitates seamless decision-making by your appointed agent.