Legal Wisconsin Medical Power of Attorney Template Edit Document Online

Legal Wisconsin Medical Power of Attorney Template

The Wisconsin Medical Power of Attorney form is a legal document that allows an individual to designate someone else to make healthcare decisions on their behalf if they become unable to do so themselves. This form plays a crucial role in planning for future healthcare needs and ensuring one's wishes are followed. It is an essential tool for proactive healthcare management and personal peace of mind.

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In the state of Wisconsin, preparing for unforeseen medical situations is a step that can significantly impact personal well-being and ensure wishes are respected regarding healthcare. A critical tool in this preparation is the Wisconsin Medical Power of Attorney form, a document that grants an individual, known as the agent, the authority to make healthcare decisions on behalf of the principal when they are unable to do so themselves due to incapacity or illness. The form covers decisions ranging from the types of medical treatment received to end-of-life care preferences, encompassing a broad spectrum of medical choices. Additionally, this form requires thoughtful consideration of potential healthcare scenarios and a clear understanding of the principal’s values and desires. It is important for the document to be completed accurately and in accordance with Wisconsin laws to ensure it is valid and effective. The process involves selecting a trusted agent, discussing wishes in depth with them, and often consulting healthcare professionals or legal advisors to make informed decisions. By taking these steps, individuals can ensure that their healthcare decisions are in trusted hands should they ever be unable to make those decisions themselves.

Document Example

Wisconsin Medical Power of Attorney grants an individual (hereinafter referred to as the "Principal") the ability to designate another person (hereinafter referred to as the "Agent") to make healthcare decisions on the Principal's behalf in the event that the Principal cannot make such decisions. This document is prepared in accordance with the Wisconsin Statutes, Chapter 155 - Power of Attorney for Health Care.

Principal Information

  • Full Name: ___________________________________________________
  • Address: _____________________________________________________
  • City: ____________________________ State: WI Zip: _____________
  • Date of Birth: _______________________________________________
  • Phone Number: _______________________________________________

Agent Information

  • Full Name: ___________________________________________________
  • Address: _____________________________________________________
  • City: ____________________________ State: WI Zip: _____________
  • Relationship to Principal: ___________________________________
  • Phone Number: _______________________________________________

Alternate Agent Information (Optional)

  • Full Name: ___________________________________________________
  • Address: _____________________________________________________
  • City: ____________________________ State: WI Zip: _____________
  • Relationship to Principal: ___________________________________
  • Phone Number: _______________________________________________

By signing this document, the Principal empowers the Agent to make healthcare decisions on the Principal's behalf, including but not limited to the refusal or consent of medical treatment, access to medical records, and the decision to donate organs, in accordance with Wisconsin law. This authority becomes effective when the Principal is determined by a healthcare professional to lack the ability to make informed healthcare decisions.

Special Instructions: On the lines below, the Principal may specify any limitations to the Agent's powers or provide any specific instructions regarding healthcare decisions.

Signatures

This document must be signed by the Principal, the designated Agent, and an alternate Agent if one is designated. It must also be witnessed by two individuals or acknowledged by a notary public in accordance with Wisconsin Statutes.

______________________________ ____________________________
Principal's Signature Date

______________________________ ____________________________
Agent's Signature Date

______________________________ ____________________________
Alternate Agent's Signature (If Applicable) Date

Witness 1: __________________________________________________
Witness 2: __________________________________________________

Or

State of Wisconsin )
)ss
County of ________________ )

Subscribed and sworn to (or affirmed) before me on this ___ day of ____________, 20__, by (name of Principal), who is personally known to me or who has produced ____________________________ as identification.

______________________________
Notary Public

My commission expires: _______________

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Form Attributes

Fact Name Description
Document Purpose Allows an individual to designate a health care agent to make medical decisions on their behalf if they are unable to do so.
Governing Law Wisconsin Statutes Section 155.10, which outlines the creation, validity, and use of a Medical Power of Attorney in Wisconsin.
Eligibility to Serve as an Agent Any competent adult who is not the health care provider or an employee of the health care provider treating the principal, unless related to the principal by blood, marriage, or adoption.
Requirements for Execution The document must be signed by the principal and two witnesses or acknowledged before a notary public to be legally valid.

Instructions on Utilizing Wisconsin Medical Power of Attorney

Creating a Medical Power of Attorney (MPOA) is a crucial step in managing your health care decisions in Wisconsin. This document allows you to appoint a trusted individual to make medical decisions on your behalf should you become unable to do so yourself. The process of filling out the Wisconsin Medical Power of Attorney form requires careful consideration and clear communication with the person you choose as your agent. Follow the steps outlined below to accurately complete the form. Remember, after completing the form, it must be signed in the presence of two witnesses to be legally valid. It's recommended to discuss your health care preferences with your appointed agent to ensure they understand your wishes.

  1. Begin by reading the entire form carefully to familiarize yourself with its contents and requirements.
  2. Fill in your full name and address at the top of the form to establish yourself as the principal.
  3. Choose a trusted individual as your agent and provide their full name, address, and contact information. Make sure the chosen person agrees to act as your agent.
  4. Discuss your health care preferences and treatment options with the agent you have chosen to ensure they understand your wishes.
  5. If you wish, appoint an alternate agent by providing their full name, address, and contact numbers. The alternate agent will step in if your primary agent is unable, unwilling, or unavailable to make decisions for you.
  6. Clear instructions about any specific medical treatments or procedures you desire or wish to avoid should be outlined in the form. Also, include conditions under which you would want or not want these treatments.
  7. Review the sections regarding organ donation, if applicable, and indicate your preferences.
  8. Ensure the form is dated to show when it was completed.
  9. Sign the document in the presence of two adult witnesses who are not related to you by blood or marriage, and who are not your health care provider or employees of a health care facility where you are receiving care. Witnesses must also not be the appointed agent or alternate agent.
  10. Have the witnesses sign and date the form, confirming they observed you signing it and that you appear to be of sound mind and free from duress.
  11. Once completed and signed, provide a copy to your appointed agent, your alternate agent (if applicable), and your primary healthcare provider.
  12. Keep the original document in a safe but accessible place, and inform family members or trusted friends where it is stored.

Completing the Wisconsin Medical Power of Attorney form is an essential step in ensuring your health care decisions are made according to your wishes, even if you become unable to articulate them yourself. By choosing a trusted agent and communicating your desires clearly, you help guide the medical care you receive and relieve your loved ones of making these difficult decisions under stress. Remember, the form can be updated or revoked at any time, should your wishes or chosen agent change.

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