I, __________________, (“Declarant”), of ____________________________________
(Address), do hereby revoke any and all power and authority granted to my physician, health care provider, or health care agent in the past, but especially the previous Health Care Durable Power Attorney attached in Exhibit 1, and dated _________________, appointing ________________________ to act as my health care Agent. All such Durable Power of Attorney’s, including but not limited to the one named above, are hereby revoked and withdrawn and this document provides notice of such revocation.
______________________ ___________________________
Declarant My Physician
I acknowledge and declare I am not the Declarant’s spouse or heir at the time of witnessing this document, nor am I associated with any health care facility in which Declarant resides or uses in any manner whatsoever.
____________________________
Witness Signature:
Witness Name:
Witness Address:
____________________________
Witness Signature:
Witness Name:
Witness Address:
Names of institutions/individuals who have been provided a copy of this revocation: Should include all parties receiving prior Agreement and the signatory thereto, “My Physician.”
Revocation of Health Care Durable Power of Attorney
Review List
This review list is provided to inform you about this document in question and assist you in its preparation. If in doubt, revoke your Health Care Durable Power of Attorney. Make sure that your Revocation accurately identifies the document(s) that you wish to revoke. The full title of each document you are revoking, as stated on the document, should be identified on the Revocation.
Because the attending physician or health care provider must receive notice of the Revocation, it is recommended that the Revocation be mailed by certified mail to the provider’s last known address. Alternatively, a copy of the Revocation may be hand-delivered to the provider, in which case the provider should sign the document acknowledging receipt of the Revocation. The latter is a better solution, all the way around. If Declarant is residing in any health care or other related facility, a copy of the Revocation should be place in his or her Medical file.
1. Make multiple copies so the original attending physician, “My physician,” has a copy as well as for your estate planning file and a separate copy for yourself.
2. Any new Health Care Durable Power of Attorney will supercede the Revocation. However, if you do take this step, you are advised to reference the former Revocation and include it as an exhibit to your new document. Do this to keep your records in order and make sure your directives are followed without document dispute.
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