Cover page. Not part of document. Do not scan.
including Power of Attorney for Health Care
This legal document meets the requirements for Wisconsin, Minnesota and Iowa.* It lets you
• Name another person to make your health care decisions if you cannot make them for yourself.
• Write down your goals and preferences for future medical care in specific situations.
The person you name is called your health care agent. You can also name alternate health care agents who can
make decisions if the person you named first or second cannot or is not willing to make those decisions. This
document gives your agent author
ity to make health care decisions on your behalf only after doctors have
determined you are incapable of making health care decisions for yourself.
This document does not give your agent authority to:
• Make financial or other business decisions.
• Make certain decisions about your mental health treatment.
Read this advance directive carefully before you complete and sign it. You should discuss your goals,
values, and this advance directive with your health care agent(s
). Unless y
ou talk with your
health care agent(s), they may not know your goals and be able to follow your instructions.
Recommendation: make an appointment with an advance care planning facilitator for help. If this advance
directive does not meet your needs, ask your health organization or attorney about other options.
To complete this advance directive
This advance directive is divided into four parts:
Part 1 – My health care agent
Part 2 – General authority of the health care agent
Part 3 – Statement of desires, care instructions or limits
Part 4 – Making the document legal
Follow the instructions in each of the four parts.
After you complete your advance directive
Take these steps:
• Talk to the person(s) you named as your agent(s) about your goals and preferences for future medical
care, if you have not already. Make sure they feel able to do this important job for you in the future.
• Give your agent(s) a copy of this advance directive.
• Talk to the rest of your family and close friends who might be involved if you have a serious illness or
injury. Make sure they know who your agent(s) is, and what your preferences are.
• Give a copy to your doctor and/or you
care facility. Make sure your preferences are understood.
*As of June 1, 2017 The name Honoring Choices Wisconsin is used under license from the Twin Cities Medical Foundation.