MAKE YOUR FREE Mental Health Care Declaration and Power of Attorney Revocation
What is a Mental Health Care Declaration and Power of Attorney Revocation?
Everything may have been perfect when you first penned a Mental Health Care Directive, but things change and your plans may have to change as well. If you need to keep your documents as current as you are, a Mental Health Care Declaration and Power of Attorney Revocation can help you reset and reassess your options. If you're getting ready to draft a brand new document, or if you've simply changed your mind and don't want it anymore, then revoking those prior documents may be the right option for you. You're allowed to rethink your plans but you have to make sure you keep up with your paperwork; after all, you don't want it to suddenly be too late to make changes. If you want your directive revoked, then take action and get it done. A Mental Health Care Declaration and Power of Attorney Revocation can erase your prior documents and give you the opportunity to start fresh.
When to use a Mental Health Care Declaration and Power of Attorney Revocation:
- You want to revoke a Mental Health Care Directive.
- You're getting ready to draft a new Mental Health Care Directive, and don't need the current one.
Sample Mental Health Care Declaration and Power of Attorney Revocation
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REVOCATION OF
I, of , , , hereby revoke my dated . The power and authority granted to my physician, psychiatrist or any mental health care provider is revoked and withdrawn and this document provides notice of such revocation.
Dated this _____ day of _______________, _____, at , .
________________________________________
I hereby witness this revocation and attest that:
(1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind;
(2) To the best of my knowledge, at the time of the execution of this revocation, I:
(a) Am not related to the maker of this revocation by blood or marriage;
(b) Do not have any claim on the estate of the maker of this revocation;
(c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law; and
(d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.
I am not the Declarant's spouse or heir at the time of witnessing this document.
We declare that we have attained the age of majority and that the Declarant signed and executed the instrument as his/her Revocation of and that he/she signed willingly, or directed another to sign for him/her, and that he/she executed it as his/her free and voluntary act for the purposes expressed; and that each of the witnesses saw the Declarant sign or another sign for him/her at his/her direction and, in the presence of the Declarant and in the presence of each other, signed the Revocation of as witness and that to the best of his/her knowledge the Declarant had reached the age of majority, was of sound mind and was under no constraint or undue influence.
I am not the Declarant's spouse nor related to the Declarant by blood or adoption at the time of witnessing this document.
I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the Declarant, that the Declarant signed or acknowledged this Revocation of in my presence, that the Declarant appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the health care agent (attorney-in-fact) of Declarant, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. I further declare under penalty of perjury under the laws of Wyoming that I am not related to the Declarant by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the Declarant upon the death of the Declarant under a will now existing or by operation of law.
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| Witness Name: | _________________________ |
| Witness Address: | _________________________ |
| _________________________ |
| _________________________ |
| Witness Name: |
| Witness Address: |
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| Witness Name: | _________________________ |
| Witness Address: | _________________________ |
| _________________________ |
| _________________________ |
STATEMENT OF WITNESSES
I declare that who signed or acknowledged this document (the "Principal") has identified himself or herself to me, that signed or acknowledged this document in my presence, that appears to be of sound mind and under no duress or undue influence. I am at least 18 years of age and not the Agent of , related to by blood, marriage, or adoption, entitled to any portion of the estate of under a will or codicil or intestate succession laws or directly financially responsible for 's health care. I am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of community care facility, or an employee of an operator of a health care facility.
| Witness Signature: | __________________________________________ |
| Witness Name: |
| Witness Address: |
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| Witness Name: | ______________________________ |
| Witness Address: | ______________________________ |
| ______________________________ |
| ______________________________ |
| Date: | __________________ |
| Witness Signature: | __________________________________________ |
| Witness Name: |
| Witness Address: |
| , |
| Witness Name: | ______________________________ |
| Witness Address: | ______________________________ |
| ______________________________ |
| ______________________________ |
| Date: | __________________ |
STATE OF KANSAS
COUNTY OF ____________________
This instrument was acknowledged before me on _____ day of ____________________, _____, by .
________________________________________
Notary Public
(Seal, if any)
My appointment expires: _________________________
Names of institutions/individuals who have been provided a copy of this revocation:
| _____ | You should sign this document in the presence of two disinterested witnesses who sign the document in your presence and in each other's presence. |
| _____ | You should sign this document in the presence of a notary who then notarizes the document. |
| _____ | The Revocation should be filed with the Mississippi Bureau of Vital Statistics of the State Board of Health. |
and Power of Attorney and Power of Attorney and Power of Attorney
