Wisconsin Power of Attorney For Health CareWisconsin Power of Attorney For Health CareWisconsin Power of Attorney For Health Care
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DIVISION OF PUBLIC HEALTH

Scott Walker
Governor
Dennis G. Smith
Secretary

1 WEST WILSON STREET
P O BOX 2659
MADISON WI 53701-2659

State of Wisconsin
Department of Health Services

608-266-1251
FAX: 608-267-2832
TTY: 888-701-1253

dhs.wisconsin.gov

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 three (3) 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 car