Create Your Advance Care Plan

Select your region, then follow the steps outlined:

• Northwest Wisconsin
  • Wisconsin locations include Barron, Bloomer, Chetek, Chippewa Falls, Eau Claire, Glenwood City, Menomonie, Mondovi, Osseo and Rice Lake.
  • Iowa location includes Decorah.
  • Minnesota locations include Albert Lea, Austin, Cannon Falls, Faribault, Lake City, Owatonna, Plainview, Red Wing, Wells and Zumbrota.
  • Wisconsin location includes Ellsworth.
  • Minnesota locations include Belle Plaine, Fairmont, Mankato, Montgomery, New Prague, St. James, St. Peter, and Waseca.
  • Minnesota location includes Caledonia.
  • Wisconsin locations include Arcadia, Holmen, La Crosse, Onalaska, Prairie du Chien, Sparta and Tomah.
    

  Northwest Wisconsin

  Create your plan:

  • Designate your healthcare agent, which is the person(s) whom you entrust to represent your wishes in the event you need someone to make decisions on your behalf.
  • Express your thoughts related to life-prolonging care, commonly related to dialysis, resuscitation, breathing machines and tube feedings. You also may note your wishes related to organ and tissue donation, and funeral arrangements.
  • Be sure to complete the form in full, including general authority of healthcare agent and statement of desires, special provisions or limitations.
  • Both witnesses and the person completing the document must sign the document on the same day. All three dates should match.
  • They should know you by verifying two forms of identification.
  • They cannot be the person named on the form as your power of attorney.
  • They cannot be your healthcare professional.
  • They cannot be your relative that is listed as your healthcare agent.
  • They must be present to watch you sign the form.
  • Personal records
  • Loved ones
  • Healthcare agent who may make healthcare decisions on your behalf
  • Healthcare professional so it can be added to your electronic health record
  • Lawyer or lock box
  • Return the completed advance directive form to your primary care provider.
  • If you do not have a primary care provider and want to have a copy on file and accessible for Mayo Clinic staff, email it to Health Information Management at HIMSDOCMGMT@mayo.edu or fax it to 507-422-0956, Attn: Health Information Management.

  If you have any questions about how to complete your paperwork, talk with the Social Work Department or the attorney that is helping you complete the paperwork, if applicable.

  Southeast Minnesota

  Create your plan:

  1. Print the form(s) that is appropriate for your state of residence. This is a legal document for your state.
     • Living Will and Medical Power of Attorney – Iowa (PDF)
     • Advance Care Directive – Minnesota (PDF)
     • Power of Attorney for Healthcare – Wisconsin (PDF), Poder notarial para la atención médica (PDF), Tsab Ntawv Tso Lus Los Ntawm Kws Lij Choj Rau Kev Kho Mob (PDF)
  2. Complete the form. Do not sign it.
     • Designate your healthcare agent, which is the person(s) whom you entrust to represent your wishes in the event you need someone to make decisions on your behalf.
     • Express your thoughts related to life-prolonging care, commonly related to dialysis, resuscitation, breathing machines and tube feedings. You also may note your wishes related to organ and tissue donation, and funeral arrangements.
     • Be sure to complete the form in full, including general authority of healthcare agent and statement of desires, special provisions or limitations.
  3. Sign the completed form in front of two witnesses or a notary republic in the state of Minnesota. This step makes it legal. Witnesses must meet these criteria:
     • They should know you by verifying two forms of identification.
     • They cannot be the person named on the form as your power of attorney.
     • They cannot be your healthcare professional.
     • They cannot be your relative that is listed as a healthcare agent.
     • They must be present to watch you sign the form.
  4. Make copies and distribute them to your:
     • Personal records
     • Loved ones
     • Healthcare agent who may make healthcare decisions on your behalf
     • Healthcare professional so it can be added to your electronic health record
     • Lawyer or lock box
  5. Complete the process by getting finalized form into your medical record so it is available for medical professionals.
  6. Return the completed advance directive form to your primary care provider.
  7. If you do not have a primary care provider and want to have a copy on file and accessible for Mayo Clinic staff, email it to Health Information Management at HIMSDOCMGMT@mayo.edu or fax it to 507-422-0956, Attn: Health Information Management.

  If you have any questions about how to complete your paperwork, talk with the Social Work Department or the attorney that is helping you complete the paperwork, if applicable.

  Southwest Minnesota

  Create your plan:

  Print the Minnesota Advance Care Directive (PDF). It is a legal document in the state of Minnesota.

  • Designate your healthcare agent, which is the person(s) whom you entrust to represent your wishes in the event you need someone to make decisions on your behalf.
  • Express your thoughts related to life-prolonging care, commonly related to dialysis, resuscitation, breathing machines and tube feedings. You also may note your wishes related to organ and tissue donation, and funeral arrangements.
  • Be sure to complete the form in full, including general authority of healthcare agent and statement of desires, special provisions or limitations.
  • They should know you by verifying two forms of identification.
  • They cannot be the person named on the form as your healthcare agent.
  • They cannot be your healthcare professional.
  • They cannot be a relative that is listed as your healthcare agent.
  • They must be present to watch you sign the form.
  • Personal records
  • Loved ones
  • Healthcare agent who may make healthcare decisions on your behalf
  • Healthcare professional so it can be added to your electronic health record
  • Lawyer or lock box

  If you have any questions about how to complete your paperwork, talk with your primary care provider or the attorney that is helping you complete the paperwork.

  Southwest Wisconsin

  Create your plan:

  1. Print the form(s) that is appropriate for your state of residence. This is a legal document for your state.
     • Power of Attorney for Healthcare – Wisconsin (PDF), Poder notarial para la atención médica (PDF), Tsab Ntawv Tso Lus Los Ntawm Kws Lij Choj Rau Kev Kho Mob (PDF).
     • Minnesota Advance Care Directive (PDF)
  2. Complete the form as a worksheet. Do not sign it.
     • Designate your healthcare agent, which is the person(s) whom you entrust to represent your wishes in the event you need someone to make decisions on your behalf.
     • Express your thoughts related to life-prolonging care, commonly related to dialysis, resuscitation, breathing machines and tube feedings. You also may note your wishes related to organ and tissue donation, and funeral arrangements.
     • Be sure to complete the form in full, including general authority of healthcare agent and statement of desires, special provisions or limitations.
  3. Call Social Work at 608-392-7900 to make an appointment to complete the document. Witnesses and copies will be provided. The final document will be added to your electronic health record.
  4. Distribute copies to your:
     • Personal records
     • Loved ones
     • Health care agent who may make healthcare decisions on your behalf
     • Lawyer or lock box

  Be sure to complete the process by getting finalized forms into your medical record so they are available for medical professionals.

  If you have any questions about how to complete your paperwork, talk with the Social Work Department or the attorney that is helping you complete the paperwork, if applicable.