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Get WI DHS F-00060 2020-2024

03 1 2 PLEASE BE SURE YOU READ THE FORM CAREFULLY AND UNDERSTAND IT BEFORE YOU COMPLETE AND SIGN IT DECLARATION TO PHYSICIANS WISCONSIN LIVING WILL I being of sound mind voluntarily state my desire that my dying not be prolonged under the circumstances specified in this document. Wisconsin.gov To Whom It May Concern Enclosed is the Declaration to Physicians Living Will form you requested. This form makes it possible for adults in Wisconsin to state their preferences for life-sustaining procedures and feeding tubes in the event the person is in a terminal condition or persistent vegetative state. O. Box 2659 Madison Wisconsin 53701-2659. You may make additional copies of the enclosed blank form. The form is also available on the If you have questions about the availability of the Declaration to Physicians Living Will form or obtaining larger quantities of the form you may contact the Division of Public Health at 608 266-1251. 2 Failing to act upon a revocation unless the person or facility has actual knowledge of the revocation. 3 Failing to comply with a Declaration except that failure by a physician to comply with a Declaration of a attempt to transfer the patient to another physician who will comply with the Declaration. F-00060A Rev. 03/13 DEPARTMENT OF HEALTH SERVICES Division of Public Health STATE OF WISCONSIN Effective Date April 6 1996 S. 154. DIVISION OF PUBLIC HEALTH Scott Walker Governor Kitty Rhoades Secretary 1 W EST W ILSON STREET P O BOX 2659 MADISON W I 53701-2659 State of Wisconsin Department of Health Services 608-266-1251 FAX 608-267-2832 TTY 888-701-1253 dhs. Be sure to read both sides of the form carefully and understand it before you complete and sign it. The withholding or withdrawal of any medication life-sustaining procedure or feeding tube may not be made if the attending physician advises that doing so will cause pain or reduce comfort and the pain or discomfort cannot be alleviated through pain relief measures. Two witnesses are required* Witnesses must be at least 18 years of age not related to you by blood marriage or adoption and not directly financially responsible for your health care. Witnesses may not be persons who know they are entitled to or have a claim on any portion of your estate. A witness cannot be a health care provider who is serving you at the time the document is signed an employee of the health care provider other than a chaplain or a social worker or an employee other than a chaplain or social worker of an inpatient health care facility in which you are a patient. Valid witnesses acting in good faith are immune from civil or criminal liability. You should make relatives and friends aware that you have signed the document and the location where it is kept. A signed form may be kept in a safe easily accessible place until needed* The document may be filed for safekeeping for a fee with the Register in Probate of your county of residence but it is not required that it be filed* The fee for filing with the Register in Probate has been set by State Statute at 8.

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