Wisconsin Statutes Social Services (Ch. 46 to 58) § 52.20. Supported decision-making agreement instrument; form

1. Help me access, collect, or obtain information, including records, relevant to a decision. If I have checked “Yes,” my supporter may help me access, collect, or obtain the type of information specified, including relevant records, but if I have checked “No,” or I have not checked either “Yes” or “No,” my supporter may not help me access, collect, or obtain that type of information:

Medical--Yes.... No....

Psychological--Yes.... No....

Financial--Yes.... No....

Education--Yes.... No....

Treatment--Yes.... No....

Other--Yes.... No.... (If “Yes,” specify the other type(s) of information with which the supporter may assist ....)

2. Help me understand my options so I can make an informed decision.

Yes.... No....

3. Help me communicate my decision to appropriate persons.

Yes.... No....

4. Help me access appropriate personal records, including protected health information under the Health Insurance Portability and Accountability Act, the Family Educational Rights and Privacy Act, and other records that may or may not require a release for specific decisions I want to make.

Yes.... No....

EFFECTIVE DATE OF SUPPORTED DECISION-MAKING AGREEMENT

This supported decision-making agreement is effective immediately and will continue until .... (insert date), or until the agreement is terminated by my supporter or me or by operation of law.

(print) Name of person designating a supporter ....

Signature ....

Date ....

CONSENT OF SUPPORTER

I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.

I, .... (name of supporter), consent to act as a supporter under this agreement.

Supporter:

(print) Name ....

Address ....

E-mail address ....

Phone number(s) ....

Signature ....

Date ....

STATEMENT AND SIGNATURE OF WITNESSES OR SIGNATURE OF NOTARY

(This agreement must be signed either by 2 witnesses who are at least 18 years of age or by a notary public.)

OPTION I:  WITNESSES

I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.

Witness No. 1:

(print) Name ....

Address ....

Phone number(s) ....

Signature ....

Date ....

Witness No. 2:

(print) Name ....

Address ....

Phone number(s) ....

Signature ....

Date ....

OPTION II:  NOTARY PUBLIC

State of ....

County of ....

This document was acknowledged before me on .... (date), by .... (name of adult with a functional impairment) and ..... (name of supporter).

Signature of notary ....

(Seal, if any, of notary)

Printed name ....

My commission expires:  ....