DIVISION OF PUBLIC HEALTH
1 WEST WILSON STREET
P O BOX 2659
Scott Walker MADISON WI 53701-2659
Governor
State of Wisconsin
Linda Seemeyer
Secretary
Department of Health Services
Telephone: 608-266-1251
Fax:608-267-2832
TTY: 711 or 800-947-3529
dhs.wisconsin.gov
Wisconsin.gov
Instructions to Complete the Power of Attorney for Health Care Form
To Whom It May Concern:
Enclosed is the Power of Attorney for Health Care form you requested. The Power of Attorney for Health Care form makes it
possible for adults in Wisconsin to authorize other individuals (called health care agents) to make health care decisions on their
behalf should they become incapacitated. It may also be used to make or refuse to make an anatomical gift (donation of all or
part of the human body to take effect upon the death of the donor).
Be sure to read all six (6) pages of the form carefully and understand it before you complete and sign it. Talk with those you
select as your health care agent and the alternate health care agent about your thoughts and beliefs about medical treatment.
Neither the health care agent nor the alternate may be your health care provider, an employee of a health care facility in which
you are a patient, or a spouse of any of those persons, unless he or she is also your relative.
Two witnesses are required. Witnesses must be at least 18 years of age, not related to you by blood, marriage, domestic
partnership, or adoption, and not directly financially responsible for your health care. A witness cannot be a health care provider
who is serving you at the time the document is signed or an employee of the health care provider unless the employee is a
chaplain or social worker. A witness cannot be an employee of an inpatient health care facility in which you are a patient, unless
the employee is a chaplain or social worker. A witness cannot be your health care agent nor have a claim on any portion of your
estate. Valid witnesses acting in good faith are immune from civil or criminal liability.
An original signed form may be kept on file with your physician. A signed Power of Attorney for Health Care form may also be
kept in a safe, easily accessible place until needed. You should make relatives and friends aware that you have created a Power
of Attorney for Health Care and the location where it is kept. Relatives and friends should also be told whom you select as the
health care agent and the alternate. The document may, but is not required to be, filed for safekeeping, for a fee, with the
Register in Probate of your county of residence. The fee for filing with the Register in Probate has been set by State Statute at
$8.00. A Power of Attorney for Health Care that is an original signed form or is a legible photocopy or electronic facsimile
copy is presumed to be valid. If you have both a Power of Attorney for Health Care and a Declaration to Physicians, the
provisions of a valid Power of Attorney for Health Care supersede any directly conflicting provisions of a valid Declaration to
Physicians.
One copy of the Power of Attorney for Health Care form is available free to anyone who sends a stamped, self-addressed,
business-size envelope to: Power of Attorney, Division of Public Health, P.O. Box 2659, Madison, Wisconsin 53701-2659. You
may make additional blank copies of the form you receive from the Division of Public Health. The form is also available on the
Department of Health Services Web page, https://www.dhs.wisconsin.gov/forms/advdirectives/index.htm. If you have any
questions about the availability of the Power of Attorney for Health Care form or obtaining larger quantities of the form, you
may contact the Division of Public Health by telephoning 608-266-1251.
Definitions ‘Department’ means the Department of Health Services. ‘Health Care’ means any care, treatment, service, or
procedure to maintain, diagnose, or treat an individual’s physical or mental condition. ‘Health care decision’ means an informed
decision in the exercise of the right to accept, maintain, discontinue, or refuse health care. ‘Health care facility’ means a facility,
as defined in State Statute 647.01(4), or any hospital, nursing home, community-based residential facility, county home, county
infirmary, county hospital, county mental health center, tuberculosis sanatorium or other place licensed or approved by the
department under State Statutes 49.70, 49.71, 49.72, 50.02, 50.03, 50.35, 51.08, 51.09, 58.06, 252.073 or 252.076 or a facility
under s. 45.365, 51.05, 51.06, 233.40, 233.41. 233.42 or 252.10. ‘Health care provider’ means a nurse licensed or permitted
under State Statute Chapter 441, a chiropractor licensed under Chapter 446, a dentist licensed under Chapter 447, a physician,
podiatrist or physical therapist licensed or an occupational therapist or occupational therapy assistant certified under Chapter
448, a person practicing Christian Science treatment, an optometrist licensed under Chapter 449, a psychologist licensed under
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