Wisconsin Medical Power of Attorney
This Wisconsin Medical Power of Attorney is a legally binding document that allows an individual (the "Principal") to designate another person (the "Agent") to make health care decisions on their behalf in the event that they are unable to do so. This document is crafted in accordance with the Wisconsin Statutes, specifically the chapter that governs powers of attorney for health care decisions.
Principal Information
- Full Name: ___________________________
- Address: ______________________________
- City: _________________________________
- State: Wisconsin
- Zip Code: ____________________________
- Phone Number: ________________________
Agent Information
- Full Name: ___________________________
- Address: ______________________________
- City: _________________________________
- State: __________________________________
- Zip Code: ____________________________
- Phone Number: ________________________
- Alternate Phone Number: ________________
Successor Agent Information (Optional)
- Full Name: ___________________________
- Address: ______________________________
- City: _________________________________
- State: __________________________________
- Zip Code: ____________________________
- Phone Number: ________________________
- Alternate Phone Number: ________________
This document grants the Agent the same authority as the Principal would possess concerning health care decisions, subject to any limitations specified in this document. The Agent's authority is effective immediately upon the Principal's incapacity, as determined by a physician. The Principal reserves the right to revoke this directive at any time.
Any decision made by the Agent on behalf of the Principal should be in the Principal's best interest and in accordance with any wishes the Principal has communicated. In the absence of specific instructions, the Agent is tasked with deciding based on what they believe the Principal would have wanted.
Special Instructions:
________________________________________________________________________________________________
________________________________________________________________________________________________
In witness whereof, the Principal has executed this Wisconsin Medical Power of Attorney on the date below:
Date: _________________________
Principal's Signature: _____________________________________
State of Wisconsin, County of ______________
This document was acknowledged before me on (Date) ______________ by (Name of Principal) ____________________________.
Notary Public: __________________________________
My Commission Expires: __________________________
Agent's Acceptance of Appointment
I, _______________________, hereby accept the appointment as Agent under the above Power of Attorney for Health Care. I understand my obligations under this document and the Wisconsin Statutes, and I agree to act in accordance with the best interests of the Principal to the best of my ability.
Date: _________________________
Agent's Signature: _____________________________________
