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Free Wisconsin Medical Power of Attorney Form

A Wisconsin medical power of attorney is called a power of attorney for health care under Chapter 155 of the Wisconsin Statutes. Build yours with our guided form and line up two qualified witnesses.

  • Download as PDF and Word
  • E-sign included

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What Is a Medical Power of Attorney in Wisconsin?

Wisconsin defines a power of attorney for health care as your designation of a health care agent to make decisions if you cannot, due to incapacity. Anyone of sound mind who is at least 18 can sign one voluntarily under Wis. Stat. § 155.05.

Wisconsin Requirements Under § 155.10

Section 155.10 sets the execution rules.

Two Witnesses

Your Wisconsin medical power of attorney must be signed in the presence of two witnesses who meet the statute’s requirements, and it must be voluntarily executed.

Who Cannot Witness

Each witness must be at least 18 and cannot, at signing, be:

  • Related to you by blood, marriage, or adoption, or your domestic partner
  • Aware of being entitled to, or having a claim on, part of your estate
  • Directly financially responsible for your health care
  • Your health care provider, or an employee of your provider or of an inpatient facility where you are a patient, other than a chaplain or social worker
  • Your health care agent

No Notary Route

Section 155.10 relies on two witnesses and does not offer a notary alternative.

Can Wisconsin Witnesses Appear by Video?

Yes, with safeguards. Wisconsin lets witnesses appear remotely by two-way, real-time audiovisual technology, but only if conditions are met.

A Wisconsin-licensed attorney must supervise the signing and may serve as one of the remote witnesses. You must attest that you are physically in Wisconsin during the call. You also display the document, confirm its page count and signature page, and make declarations to the witnesses and the attorney.

Chaplains and Social Workers Can Witness

Wisconsin’s employee ban has an exception for chaplains and social workers. If you are in the hospital, one of them may be able to witness your document when other staff cannot.

How to Sign Your Wisconsin Medical Power of Attorney

Work through your Wisconsin medical power of attorney form with these steps:

  1. Name your health care agent and an alternate.
  2. Add any instructions or limits on your agent.
  3. Choose two witnesses who clear every item on the disqualification list.
  4. Sign in their presence, or use attorney-supervised video witnessing.
  5. Have both witnesses sign.
  6. Provide copies to your agent and the clinics that treat you.

What to Include in Your Wisconsin Form

Wisconsin publishes a statutory form in § 155.30, and the Wisconsin Department of Health Services distributes it. A complete Wisconsin medical power of attorney usually includes:

  • Your health care agent and an alternate
  • Any instructions about treatment
  • Signatures of you and two qualified witnesses

The Department of Health Services form notes you can revoke your power of attorney for health care in several ways. One is expressing your intent to revoke in the presence of two witnesses; another is signing a new one.