Wisconsin Medical Power of Attorney (POA) Form

We all need help sometimes, but some of us need it more than others. In situations when you can’t longer make decisions on your own, and especially when you can’t make decisions on your mental and physical health, you can find a person who will make these decisions for you. You can choose the person who you trust with your health and then appoint him as your representative. To do this, you need to create the “Medical Power of Attorney Form” (or the MPA form).

By doing so, you give your representative the right to:

  • Chose treatment for you;
  • Select medical procedures;
  • Speak on behalf of you about your physical and mental health.

This is a serious decision. That’s why you need to think twice before choosing someone as your representative in such a complex question. You have to be sure this person will represent your will. To protect yourself, you can discuss your preferences for treatment with him and explain to him his role in the whole process.

Remember that you have all the right to cancel the medical power of attorney form any time you like, but only while you’re still capable of doing so.

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The minute doctors decide that you’re unable to speak for yourself in the context of your mental and physical health, you lose your voice forever. That’s why it’s extremely important to choose the right person as your representative and to discuss with him all possible measures of caring for you in the days when you no longer have a sound mind.

In some states, local laws require notarial attestation of the form, while others ask for the presence of witnesses while completing the form. It differs from state to state.

Wisconsin Laws and Requirements

In Wisconsin, the MPA is regulated by chapter 155 of the Wisconsin Statutes.

According to it, to complete the MPA, two witnesses are required, and here’s something which these witnesses can’t be:

  • younger than 18 years old;
  • be the principal’s relatives, close friends, someone they may theoretically know;
  • with criminal past.

The principal, the one creating the MPA, has to be at least 18 years old. He has to tell his family about the completed form, and they have the right to know who will represent his health care interests. They also have the right to know where the MPA is kept.

Both witnesses and the principal need to sign the form at the same time. To sign the form, the principal has to be of a sound mind, and that’s the kind of decision only doctors can make. Two physicians, or a psychologist and a physician can identify the incapacity of the principal.

Something that can’t be identified as the incapacity:

  • eccentricity;
  • old age;
  • physical disability.

In Wisconsin, a principal can revoke and annul the MPA at any time and any place by:

  • tearing;
  • burning;
  • defacing;
  • canceling;
  • obliterating the form.

A principal can also show his or her will of revoking the form by writing the paper with his intentions (which needs to be signed and dated by a principal) or by expressing his or her intention verbally in the presence of two witnesses. At this time, the principal’s health representative has to record the date, place, and time of the revocation.

No health care provider or health care facility can be charged with a crime or with professional misconduct for:

  • claiming incapacity of the principal made on a detailed examination of the principal;
  • non-compliance with agreements of the MPA due to different factors, unless physicians refuse to move the principal to physicians who can comply;
  • operating on decisions made by the principal’s health care representative;
  • making decisions of good faith under the MPA.

Any health care decision of the principal made under the MPA can’t be considered as constituting suicide.

Insurers have to pay for all medical services and goods of the principal, even if it’s the principal’s representative who requests them.

Wisconsin Medical Power of Attorney Form Details

Document Name Wisconsin Medical Power of Attorney Form
State Form Name Wisconsin Power of Attorney for Health Care
State Laws Wisconsin Statutes and Annotations, Sections 155.01 to 155.80
Signing Requirements Two Witnesses
Who Can’t Be the Agent? Section 155.05(3)
Who Can’t Be the Witness? Section 155.10(2)
Avg. Time to Fill Out 8 minutes
# of Fillable Fields 21
Available Formats Adobe PDF

Filling Out the Form

Here are the instructions on completing the MPA form in Wisconsin. Using them, you can complete this form on your own.

  • Download the Wisconson MDPOA Form Template

In the beginning, you need to download the template of the MDPOA form. Use our form building software to make this process as quick as possible.

  • Complete Your Data Information

Write in the heading of the form your personal information: full name, place, date of birth, age, full address, email, and telephone number.
Part for data information of Wisconsin medical power of attorney

  • Confirm Your Representative

In this section, you need to state your representative, fill in the form of his or her full name, full address, email, and telephone number.
Representative confirming section of a medical power of attorney template for Wisconsin

  • Choose the Alternate Health Care Agent

Here you appoint your second representative, write down his data, as of his or her full name, address, and phone number. Plus, state the type of relationships with your alternate health care agent.

Also, specify the conditions on which you can be admitted incapable.
Alternate health care agent choosing of Wisconsin mpoa

  • Set the Instructions for the Representative

In this section, you need to:

  • define your representative and alternate health care agent’s responsibility zone on making health care decisions on your behalf;
  • set limitations in their actions affecting your health (especially the ones about your mental health treatment);
  • clarify your position on nursing homes and other medical residential facilities;
  •  illuminate your thoughts on the possibility of feeding you with a feeding tube;
  • set some of your specific desires or limitations in your treatment, which your representative or alternate health care agent has to consider before making any decisions.
    Instructions for Representative part of Wisconsin medical poa
  • Sign the MDPOA Form

After all the settled instructions, after reading and rereading them very carefully, you have to sign the form and specify the date of completing the document.
Signing part of Wisconsin mdpoa form

  • Ask Witnesses to Sign the MDPOA Form

You need two witnesses to complete the form. They have to sign the document simultaneously as you do and have to indicate the date of leaving their signatures in your MPA form.

Friendly reminder: your representative or alternate health care agent can’t be your witnesses.
Witnesses signatures part of mdpoa template for Wisconsin

  • Ask Your Representative and Your Alternate Health Care Agent to Sign the MDPOA Form

Your representative and alternate health care agent have to state they understand your desires and requests on the medical treatment, and after that, they need to sign the form and write down their addresses.

In this section, you can also specify your thoughts on anatomical gifts. e.g., whether you want to donate your organs after your death or not, and if you want to give them for anatomical study.

Leave your signature, indicate the date, and the MPA form is finally complete.
Representative and alternate health agent signing sectiong of Wisconsin mpoa document

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Published: Jul 2, 2022