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Create Your Advance Care Plan

Click on your location below, then follow the steps outlined.  

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

Northwest Wisconsin

  1. Print the Wisconsin Power of Attorney for Health Care form. This is a legal document for your state.

  2. Complete the form. DO NOT SIGN IT.
    • Designate your health care 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 health care agent and statement of desires, special provisions or limitations.
  3. Sign the completed form in front of two witnesses. This step makes it legal. If the form is not completed properly, the document will be invalid. Witnesses must meet these criteria:
    • 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 health care professional.
    • They cannot be your relative that is listed as your health care agent.
    • They must be present to watch you sign the form.
  4. Make copies and distribute them to your:
    • Personal records
    • Loved ones
    • Health care agent who may make health care decisions on your behalf
    • Health care professional so it can be added to your electronic health record
    • Lawyer or lock box
  5. Complete the process by getting the finalized form into your medical record so it is available for medical professionals.
    • 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.

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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.
  2. Complete the form. DO NOT SIGN IT.
    • Designate your health care 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 health care 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 health care professional.
    • They cannot be your relative that is listed as a health care agent.
    • They must be present to watch you sign the form.
  4. Make copies and distribute them to your:
    • Personal records
    • Loved ones
    • Health care agent who may make health care decisions on your behalf
    • Health care 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.

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Southwest Minnesota

Create Your Plan

  1. Print the Minnesota Advance Care Directive form. It is a legal document in the state of Minnesota.

  2. Complete the form. DO NOT SIGN IT. 
    • Designate your health care 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 health care 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 health care agent.
    • They cannot be your health care professional.
    • They cannot be a relative that is listed as your health care agent.
    • They must be present to watch you sign the form.
  4. Make copies and distribute them to your:
    • Personal records
    • Loved ones
    • Health care agent who may make health care decisions on your behalf
    • Health care professional so it can be added to your electronic health record
    • Lawyer or lock box
  5. Complete the process by getting the 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 your primary care provider or the attorney that is helping you complete the paperwork.

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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.
  2. Complete the form as a worksheet. DO NOT SIGN IT.
    • Designate your health care 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 health care 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 health care 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.

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