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DIVISION OF PUBLIC HEALTH 1 WEST WILSON STREET P O BOX 2659 MADISON WI 53701-2659 Scott Walker Governor Dennis G. Smith Secretary State of Wisconsin Department of Health Services DHS.Wisconsin.gov

The form also allows these health care agents to make health care decisions on behalf of adults who cannot make health care decisions on their own. The Power of Attorney form is designed for people who desire to make decisions about their health care in the event that they become incapacitated with mental or physical disabilities or illnesses. When you request the form below, please make sure you are comfortable with the information and make sure you understand that you have granted us the power to act as health care agents on your behalf. Please be aware that once you use our form, you will be able to make health care decisions with others on your behalf, even though you may not have the ability to have decisions made for you, or you may not be able to understand a lot of the information contained on the form. Please consult with a family practitioner, physician or other healthcare professional before you fill out this application and before making any health care decisions. To begin making health care decisions for yourself or a loved one, please go to the Health Care agents page. The Power of Attorney for Health Care form can be viewed in the Wisconsin Health Care Agents Application, or you can download the form below (complete the Power of Attorney form and sign it). Once you have this form, you can fill it out, and then either fax back to Wisconsin Health Service or submit it by mail to: DHS WI. Attn: WI Health Service 1200 Wisconsin Ave #721 Madison WI 53703 Note: If you do not know how to complete this form, please contact us, so we can help you. To make sure this Power of Attorney form is received in Wisconsin, you should not submit it electronically to Wisconsin Health Service from the internet. Mail the form to: DHS WI. ATTN: WI Health Service 1200 Wisconsin Ave #721 Madison WI 53703 To make sure this Power of Attorney form is received in Minnesota, you should not submit the form electronically to Minnesota Health Service from the internet. Instead, submit it by mail to: DHS MN ATTN: MN Health Service 700 Minnesota Ave NE St. Paul MN 55108 To make sure this Power of Attorney form is received in the District of Columbia, you should not submit it by mail to the Department of Health and Mental Hygiene. Instead, submit it by mail to: WHS DC Attn: DC Health Care Agents 1901 Wisconsin Ave. NW Washington DC 20056 To prevent errors on your Power of Attorney form, please use this checklist of questions.

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