WISCONSIN DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(Comprehensive Form – Customizable Template)

[// GUIDANCE: This template is drafted to comply with Wis. Stat. ch. 155 (Powers of Attorney for Health Care) and incorporates HIPAA authorization language under 45 C.F.R. pts. 160 & 164. Practitioners should confirm that any customization preserves statutory compliance, witness eligibility, and execution formalities.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title.
WISCONSIN DURABLE POWER OF ATTORNEY FOR HEALTH CARE (the “Agreement”).

1.2 Parties.
(a) “Principal”: [PRINCIPAL LEGAL NAME], of [ADDRESS] (“Principal”).
(b) “Agent”: [AGENT LEGAL NAME], of [ADDRESS] (“Agent”).
(c) “Alternate Agent(s)”: [ALTERNATE #1 NAME] and [ALTERNATE #2 NAME] (each an “Alternate Agent”).

1.3 Recitals.
A. Principal desires to appoint an Agent to make Health Care Decisions on Principal’s behalf if Principal lacks decisional capacity.
B. This Agreement is executed pursuant to, and shall be construed in accordance with, Wisconsin’s health-care-power-of-attorney statute and other applicable law.
C. Consideration is acknowledged by mutual promises contained herein.

1.4 Effective Date.
This Agreement is effective upon the later of (i) the date of execution, or (ii) the date on which Principal is determined to lack decisional capacity by two licensed physicians, one of whom is Principal’s attending physician, unless Principal elects immediate effectiveness at Section 3.2(b).

1.5 Governing Law & Jurisdiction.
This Agreement shall be governed by the laws governing health-care powers of attorney of the State of Wisconsin (“state_healthcare_law”). Venue for any proceeding shall lie exclusively in the [COUNTY] County Probate Court (“state_probate_court”).

2. DEFINITIONS

For purposes of this Agreement, capitalized terms have the meanings set forth below.

“Advance Directive” means any written instruction, including this Agreement, recognized under Wisconsin law concerning the provision of Health Care to Principal when Principal is incapacitated.

“Agent” has the meaning assigned in Section 1.2(b); references include any duly acting Alternate Agent.

“End-of-Life Treatment” means life-sustaining procedures, artificially administered nutrition or hydration, and any other medical intervention that primarily prolongs the dying process when death is imminent or Principal is in a persistent vegetative state.

“Good Faith” means honesty in fact and the observance of reasonable standards of care applicable to Agents under Wis. Stat. ch. 155.

“Health Care” and “Health Care Decision” have the meanings ascribed in Wis. Stat. § 155.01(6)–(7), including consent, refusal, or withdrawal of any care, service, or procedure to maintain, diagnose, or treat Principal’s physical or mental condition.

“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and the privacy regulations at 45 C.F.R. pts. 160 & 164.

“PHI” means “protected health information,” as defined in 45 C.F.R. § 160.103.

“Principal” has the meaning assigned in Section 1.2(a).

3. OPERATIVE PROVISIONS

3.1 Appointment of Agent.
Principal hereby appoints Agent to make any and all Health Care Decisions for Principal consistent with this Agreement and applicable law.

3.2 Scope & Durability.
(a) Durable Authority. The authority of Agent is durable and shall not be affected by Principal’s subsequent incapacity.
(b) [PLACEHOLDER—EFFECTIVENESS OPTION: Check one]
☐ Delayed Effectiveness (default) — Authority begins upon certification of incapacity as described in Section 1.4.
☐ Immediate Effectiveness — Authority begins immediately upon execution and continues if Principal becomes incapacitated.

3.3 Health-Care Decision Authority.
Subject to the limitations herein, Agent may:
(i) consent to, refuse, or withdraw any Health Care;
(ii) admit or discharge Principal from any facility;
(iii) contract and apply Principal’s funds for Health Care;
(iv) access medical records and receive PHI;
(v) execute waivers, releases, and other documents related to Health Care.

3.4 End-of-Life Provisions.
(a) Life-Sustaining Procedures. Principal [PLACEHOLDER—INITIAL ONE]:
☐ directs that End-of-Life Treatment be withheld or withdrawn when medically appropriate.
☐ directs that End-of-Life Treatment be provided to prolong life to the greatest extent practicable.
☐ authorizes Agent to decide consistent with Agent’s assessment of Principal’s best interests.
(b) Pain Relief. Regardless of the option selected above, Principal authorizes medication or treatment necessary to alleviate pain or discomfort, even if such medication may hasten death.

3.5 HIPAA Authorization.
Principal designates Agent (and any Alternate Agent) as Principal’s “personal representative” for HIPAA purposes, thereby authorizing any covered entity to disclose PHI to Agent and to accept instructions from Agent regarding PHI. This authorization is effective immediately and survives Principal’s death to the extent necessary to carry out health-care decisions made pursuant to this Agreement.

3.6 Nomination of Guardian.
Should a court determine that a guardian of person is necessary, Principal nominates Agent to serve, consistent with Wis. Stat. § 155.10.

3.7 Successor & Co-Agents.
If the acting Agent is unwilling, unable, or not reasonably available to carry out the duties herein, authority passes to the Alternate Agent(s) in the order named in Section 1.2(c). Only one Agent may act at a time unless specifically permitted by an executed rider.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal’s Representations.
(a) Capacity. Principal affirms having legal capacity to execute this Agreement.
(b) Revocation of Prior Instruments. Principal revokes all prior health-care powers of attorney except [PLACEHOLDER—LIST OR “NONE”].

4.2 Agent’s Representations (acknowledged in Section 10).
(a) Competence & Willingness. Agent is at least 18 years old, competent, and willing to serve.
(b) No Disqualifying Status. Agent is not Principal’s health-care provider, employee of such provider, or owner/operator of a health-care facility in which Principal resides, unless permitted by Wis. Stat. § 155.03(2).
(c) Conflict Disclosure. Agent has disclosed any potential conflicts of interest to Principal.

4.3 Survival. The representations and warranties in this Section 4 survive the execution and any revocation of this Agreement.

5. COVENANTS & RESTRICTIONS

5.1 Agent’s Duties. Agent shall:
(a) act in Good Faith and in accordance with Principal’s expressed wishes, or if unknown, in Principal’s best interests;
(b) consult, when feasible, with family members and relevant professionals;
(c) maintain a contemporaneous written record of significant decisions;
(d) promptly inform health-care providers of the existence and terms of this Agreement.

5.2 Principal’s Rights. Principal retains the right to:
(a) give direct instructions to health-care providers, which supersede Agent’s decisions while Principal has decisional capacity;
(b) revoke this Agreement in whole or part pursuant to Section 6.2;
(c) request information from Agent and health-care providers at any time.

5.3 Restrictions on Agent. Unless expressly authorized in an attached rider, Agent may not:
(i) delegate authority;
(ii) make decisions regarding non-therapeutic abortion or sterilization;
(iii) consent to psychosurgery, electroconvulsive treatment, or experimental research without separate informed consent procedures required by law.

6. DEFAULT & REMEDIES

6.1 Events of Default. The following constitute default by an Agent:
(a) acting outside the scope of authority;
(b) failure to act in Good Faith;
(c) incapacity, resignation, or death;
(d) judicial determination of misconduct or abuse.

6.2 Revocation & Removal.
(a) Principal may revoke this Agreement, or remove an Agent, by:
(i) executing a subsequent written revocation;
(ii) orally informing the Agent and two witnesses; or
(iii) destroying all executed originals.
(b) A court of competent jurisdiction may remove an Agent upon petition by an interested party for cause.

6.3 Remedies.
(a) Injunctive Relief. Any interested person may seek injunctive or declaratory relief (“healthcare_directive”) in the state probate court to enforce or enjoin actions under this Agreement.
(b) Attorneys’ Fees. In any proceeding arising under this Agreement, the prevailing party may recover reasonable attorneys’ fees and costs.
(c) Cure. An Agent in default under Section 6.1(a)–(b) shall, upon written notice, have a [10]-day period to cure before removal, unless immediate action is required to prevent substantial harm.

7. RISK ALLOCATION

7.1 Indemnification. To the fullest extent permitted by law, Principal shall indemnify and hold harmless Agent and any Alternate Agent from any loss, liability, or expense, including reasonable attorneys’ fees, arising from acts or omissions performed in Good Faith under this Agreement (“agent_good_faith”), except to the extent caused by willful misconduct or gross negligence.

7.2 Limitation of Liability. An Agent acting in Good Faith shall not be liable for any injury, damage, or loss arising from health-care decisions made pursuant to this Agreement (“good_faith_standard”).

7.3 Insurance. Nothing herein precludes Agent from seeking coverage under any applicable liability insurance.

7.4 Force Majeure. Agent shall not be deemed in breach for failure to act when prevented by events beyond Agent’s reasonable control (including natural disaster, war, or widespread system failure).

8. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement shall be construed and enforced in accordance with “state_healthcare_law.”

8.2 Forum Selection. Exclusive jurisdiction and venue shall lie in the “state_probate_court” located in [COUNTY] County, Wisconsin.

8.3 Arbitration. Arbitration is expressly unavailable and shall not be compelled (“not_available”).

8.4 Jury Waiver. No jury-trial waiver is provided (“not_available”).

8.5 Equitable Relief. The parties acknowledge that violations of this Agreement may cause irreparable harm; accordingly, the court may grant injunctive relief to enforce the healthcare directive.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver. This Agreement may be amended only by a written instrument executed with the same formalities as this Agreement. Waiver of any provision must be in writing and shall not be construed as waiver of any other provision.

9.2 Assignment & Delegation. Agent’s authority is personal and may not be assigned or delegated except to an Alternate Agent as expressly provided herein.

9.3 Successors & Assigns. This Agreement binds and benefits Principal, Agent, Alternate Agents, and their respective heirs, executors, administrators, and permitted assigns.

9.4 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force, and the unenforceable provision shall be reformed to the minimum extent necessary to effectuate its purpose.

9.5 Integration. This Agreement constitutes the entire understanding regarding the subject matter and supersedes all prior oral or written directives, except as expressly incorporated.

9.6 Counterparts; Electronic Signatures. This Agreement may be executed in multiple counterparts, each of which is deemed an original, and all of which together constitute one instrument. Electronic signatures and counterparts shall be valid and binding.

10. EXECUTION BLOCK

[// GUIDANCE: Wisconsin requires TWO qualifying adult witnesses OR a notary public. The witnesses must not be related, entitled to any portion of the estate, directly financially responsible for the Principal’s health care, or health-care providers of the Principal (with limited exceptions).]

10.1 Principal.
I, the undersigned Principal, declare that I have read this Wisconsin Durable Power of Attorney for Health Care, understand its contents, and sign it willingly.

| ____ | _____ |
| Signature of Principal | Date |

10.2 Statement of Agent.
I hereby accept my appointment as Agent and agree to act in Good Faith consistent with Principal’s wishes and Wisconsin law.

| ____ | _____ |
| Signature of Agent | Date |

10.3 Statement of Alternate Agent(s).
[Duplicate block for each Alternate Agent.]
| ____ | _____ |
| Signature of Alternate Agent | Date |

10.4 Witness Attestation.
We declare that the Principal is personally known to us, appeared to be of sound mind, and signed this instrument voluntarily in our presence. We are at least 18 years old and qualify as witnesses under Wis. Stat. § 155.10(1)(c).

| Witness #1 Signature ____ | Date _ |
| Printed Name _____ | Address ______ |

| Witness #2 Signature ____ | Date _ |
| Printed Name _____ | Address ______ |

10.5 [OPTIONAL] Notarization.
State of Wisconsin          )
County of [___]        )

Subscribed and sworn before me on ___ , 20___, by [PRINCIPAL NAME].

Notary Public, State of Wisconsin
My commission expires: ______

[// GUIDANCE:
1. File an executed original in a readily accessible location and provide copies to the Agent, Alternate Agents, and primary care physician.
2. Review and update periodically, particularly after major life events or statutory changes.
3. Consider attaching a living-will supplement or organ-donation directive if desired.]